Why Do Marriage Therapists Undertreat Sexual Problems?

Sexual attraction and activity between spouses is essential yet seldom discussed

Posted Jan 19, 2012

Lack of sexual intimacy invites a back-to-back relationship. Stock Photography
Source: Stock Photography

A recent study asked marriage therapists how often they asked the couples with whom they worked about their sex lives, and how extensively they encouraged to couple to focus on sexual issues in their treatment sessions for marital problems

Surprisingly few therapists inquired in detail about the frequency and satisfaction levels of sexual intercourse, or focused routinely on sexual issues during treatment.  That fact in itself is problematic, particularly given the results of the 2011 report from the National Marriage Project in which happily married couples ranked sex right up there with communication, commitment and generosity as top factors in their marital satisfaction.

Even more problematic was the revelation of gender differences among therapists.  Male marriage counselors more often encouraged discussion of sexual issues.  Women marriage counselors focused on sexual functioning significantly less.  Since the majority of marriage therapists are women, that means that most couples' therapists do not sufficiently explore this essential aspect of marital functioning.

The relevance of this trend hit me personally when I recently published a blogpost on how to determine the effectiveness of a marriage therapy.  A woman named Cynthia wrote a Comment asking why I had not included the therapist's encouragement of discussion about sexual issues in my set of questions.   

"Woops!" I realized regretfully. "I'm personally making the mistake on this questionaire that women therapists in general seem to make with clients." 

Adding to my blogpost a question on how much a therapist attends to sexual issues in the marriage treatment was easy.  The harder part for me in responding to Cynthia's question was answering the WhyWhy had I omitted a question on sexual issues in my initial posting?

For sure the omission was inadvertent, not on purpose.  I totally endorse the importance addressing sexual functioning in marriage therapy.  The omission was an error.  Yet finding the sources of errors can be enlightening with regard to repeating similar errors.

In my own clinical work I include questions about sexual functioning in the initial paperwork couples fill out prior to their first session.  If there are any indications of sexual difficulties, my routine is to ask for more details and address the difficulties early in treatment.  Difficulties can include low desire, excessive desire (a form of love addiction), difficulties in sexual performance, anxieties about sex and a host of other issues.

So here's some speculations on the possible sources of my personal mistake with the inadvertent omission.  In addition, I'll be sharing research on the subject.  One word of advice though.  Be sure that you read the superb insights that readers are sharing in the Comments after this article.  Please share your thoughts too.  This is an interactive work-in progress.

Embarrassment  Discomfort about talking publicly about a private issue like sex could hold a therapist back from detailed questioning. As one reader has written in the Comments section (Cynthia, who first motivated me to write this article), the healthier the therapist's sexual life, the more comfortable he or she is likely to feel addressing sexual issues with clients. 

Personally, having been a therapist for over thirty-five years, married for over forty years in a sexually robust partnership, and a gramma many times over I feel pretty immune from discomfort about discussing sexual issues with clients.

At the same time, after reading an excellent Comment to this article on this issue, I became aware that I am in fact more comfortable treating female sexual dysfunction than male difficulties.  Fortunately I have ready access to a male office-suite colleague, Dale Petterson.  I generally invite him to work jointly with me when I'm treating male clients with sexual functioning difficulties. (See details in the Comments section).

For the most part however, talking about deeply personal issues with clients is what a therapist does all day every working day.  In this regard sexual topics are not all that different, though perhaps more conventionally regarded as private, than much of what we routinely discuss in treatment. Again, the squeamishness dimension, for me at least, is not the cause of my not having included a question on talking about sex in my therapist evaluation suggestions.

Sex-therapy skill-set insufficiencies  Uncertainty about what to do to ameliorate sexual difficulties could be a second reason why marriage therapists tend to give sexual issues short shrift.  

I'm sure that for many therapists this is a very real factor.  Sexual therapy tends to be regarded as a therapy specialty area.  Sex and marriage therapist Barry McCarthy notes this reality in his excellent 2008 Journal of Contemporary Psychotherapy article on this subject called "Integrating Sex Therapy Interventions with Couple Therapy." 

McCarthy explains that the couple counseling and sexual counseling fields have grown up as separate disciplines, each with their own techniques, their own training programs, and their own conferences and journals for sharing new developments in the field.  It's no wonder therefore that many marriage therapists may feel insecure addressing sexual problems because of feeling insufficiently equipped with the necessary skill sets.

For women, low sexual desire is the most frequent concern in the realm of sexual functioning (Basson, 2006).  Practical warm-up suggesions can make a big difference, along with information that helps with attitudes toward sex, for many clients.  Prior sexual trauma however may have turned off the sexual switch.  Unfortunately, too few therapists have been trained in the kinds of EMDR and energy therapy treatment techniques that can undo the impacts of earlier sexual trauma.  In fact, I'm not so sure that sex therapists have these skills either. 

Thinking back on recent cases of low or zero desire, male as well as female, that I've treated, these newer energy therapy methods have been key to the successful outcomes.  In one case, for instance, a husband felt unable to interact sexually with his wife.  He needed to be able to track back to the incident that long ago had occurred between them for which he was subconsciously punishing her by withholding sexual attention.  In addition, the energy psychology intervention called The Emotion Code identified and released the trapped negative emotion from an incident earlier in his life that had seriously undermined his sexual confidence.

Conflict resolution skill-set deficits  The most common cause of marital conflicts over sex in the couples I've treated in my clincial practice is conflict over sexual frequency.  Clinical research reports the same finding (Basson 2006).  

Left untreated, frequency conflicts can, over time, yield ever-wider rifts between the couple, posing a risk for all-or-nothing polarization.  When one spouse begins feeling that their partner wants sex all the time, he or she may eliminate touching or hugging and even smiles for fear that any [positive contact will release the partner's perpetual urge for copulation.  Meanwhile the other spouse begins to believe that his or her partner never is willing to participate in sex. 

Yet if, for instance, one spouse prefers daily intercourse and the other's preference is something closer to weekly, this is a resolvable conflict.  Most couples, with a therapist's help, can explore their underlying concerns and end up with an action plan that works for both of them.

Unfortunately, too few therapists are skilled in win-win conflict resolution strategies. Many marriage therapists, alas, lack sufficient conflict resolution skills training to succeed in helping couples talk cooperatively until they find mutually agreeable solutions to their sexual differences.

Therapist training programs probably need to shoulder at least a piece of the responsibility for insufficient therapist attention to sexual matters.  Treatment of sexual difficulties needs to be moved up further toward the top of the list of skills that graduate schools teach counselors-in-training.  More explicit training in dealing with sexual difficulties could add to changes in how regularly therapists address sexual issues in marriage treatments. 

Assessment techniques  Barry McCarthy suggests particularly helpful questions that it would behoove therapists to ask in their initial assessment sessions with a new couple. In what ways do you view your sexual relationship as a strength in your relationship?  As a source of disappointment or difficulties?  When in your marriage has your sexual acitivity been the most positive?  When has it been problematic? 

C. Risen, a therapist who also writes about addressing sexual issues in marriage therapy, describes these questions as inviting the couple to tell their sexual story.  McCarthy adds that asking about their sexual story needs to be elevated on a par with exploring each spouse's present and family-of-origin relationship experiences.

Technical sexual treatments There definitely are sexual difficulties that lie out of my realm of expertise and that I would therefore refer to a specialist.  Erectile disfunction, women's pain on intercourse, and medication-induced loss of sexual functioning need medical referrals.  Premature ejaculation merits a sex therapist rather than a therapist who specializes in relationships.

What is very clear from psychological research is that serious sexual functioning difficulties rarely remit spontaneously after therapy has produced improvements in the overall marriage relationship.  McCarthy emphasizes this point in his 2008 article on sexual difficulties and marriage therapy, and refers to corroborating research (Bancroft et al. 2003), (LoPiccolo and Friedman, 1988). 

What matters in marriage?    McCarthy suggests that therapists may not realize how vital a role sexuality plays in marital happiness

Many studies give evidence of the positive contributions a healthy sexual relationship makes to both personal emotional health and relationship vitality. As a woman in my 1970's women's liberation group once said, "Sex is a positive way of spending time."

The key however that therapists can easily and mistakenly misunderstand is the potency of problematic sexual functioning.  Keim and Lappin's 2002 study clarified that when sex becomes dysfunctional, conflictual, or absent, sexual issues can undermine all the good aspects of a marriage relationship.  While it's lovely that good sex enhances marriage satisfaction, the fact that bad sex not only detracts but can kill a good marriage says that ignoring sexual problems in marriage therapy can prove disastrous. 

Are we there yet?  Personally, none of the issues I've listed so far seem to have factored into my omission in my therapist-evaluation blogpost of questions regarding discussing sexual issues.  There must have further sources beyond discomfort with talking about sexual issues, insufficient treatment skills, or lack of awareness of the vital importance of a robust sexual relationship in marriage.

What other factors could have been the culprits? 

Gender differences  Cynthia, the writer of the Comment on my earlier blogpost, herself suggested an alternative factor.  For me, this facator hits the nail on the head.

"It's like sex is just fundamentally undervalued [by women]," Cynthia wrote.  "Communication, I think, is fundamentally female. Easy for female therapists to find focus on it. Sex, though, has parallel import for men..."

The myth of fix the social intercourse and the sexual intercourse will follow.  This mistaken belief at one time also used to limit my responsiveness to complaints of sexual difficulties.

As MCarthy writes, quoting a 2003 study by Bancroft et al, "it is rare that sexual dysfunction spontaneously reits even when other individual and reolationship problems are resolved."  McCarthy goes on to advise, "therapy can concurrently address both depresson and sexuality, in this case referencing a 2003 study by Snyder and Whisman. 

Mistaken ideas of therapeutic sequencing.  McCarthy's excellent article also highlights a related common therapeutic misconception, the belief that therapists should first deal with overt "core issues" like alchol abuse, violence and family of origin conflicts; then address relationship problems, and lastly, if necessary, focus explicitly on sexual issues. 

In this regard I am a strong believer in the general principle of starting each session by asking clients what they would like to focus on.  Clients know best what they need to work on and in what sequence. 

At the same time, I reserve the right to add my own hunches on what I think it's important to use a session for.  If I know that there have been sexual difficulties, and no one is putting these issues on the table, I do.  That's because many people are reluctant, ashamed, or embarrased to admit that they need to put sexuality out as a session focus.  Or, part of the sexual problem is perpetual avoidance, which they are at risk for doing in therapy as well as at home.

Here's a case in point  I recall a case from many years back in which I made a significant therapeutic error in this regard. Let's call the couple Mr and Mrs Smith. 

Mrs. Smith's main complaint in the marriage was her husband's hearing deficit vis a vis her viewpoints.  Mr. Smith's ears were fine.  His narcissism was not.  Whatever the topic, he was certain that his viewpoint was right. And he frequently pointed out to his wife how she, by contrast, quite consistently spoke wrongly.  Mr. Smith's listening-skills deficit made him difficult for me to work with as a therapist as well as for his wife to live with.  It's hard for a therapist to get information through to a client who dismisses everything said to him 

Mr. Smith's primary concern in the marriage, by contrast, was his wife's sexual withholding.  Mrs. Smith acknowledged openly that she felt perpetually angry at her husband.  When she felt angry she felt neither sexual nor loving.  From her perspective, the infrequency of their sexual enjoyment was 100% caused by her husband's provocative dismissive listening. 

On one level, Mrs. Smith was right.  She was withholding sex because she was angry at being unable to connect with her husband in verbal intercourse.  In addition, his non-listening triggered a host of family-of-origin issues about feeling undervalued, uncared for, voiceless and powerless.

At the same time, Mr. Smith's blockages to hearing or taking seriously anything his wife said were definitely exacerbated by his continual sense of sexual frustration.  Withholding sex was a provocative act by his wife, not a neutral phenomenon with no impact on him.  His anger in response to this provocation left him with little desire to become a better listener. 

When a cyclic interaction like this becomes clear, the therapist is well advised to help each partner address their own part of the cycle.  As someone once astutely said, "We's don't change. Individuals do." 

Here's the true and sad confessions part of the Smith therapy case.  As a female therapist, my sympathies led me to focus immediately and extensively on the listening skills.  For sure, both spouses needed to upgrade their listening if they were to have any chance at a more harmonious and gratifying relationship. 

The difficulty was my asymetrical attention to his and to her concerns.  Initially at least, I allowed the sexual issues of the couple slipped onto the therapeutic back-burner.

Also, as the saying goes, to a (wo)man with a hammer, the world's a nail.  As a female therapist I have particular interest in, and have developed particular skills at rectifying, communication skills deficits.  What we feel good at is what we are likely to do most of. 

Mr. Smith himself played a part in the situation.  He felt embarrassed, maybe even ashamed, to have succumbed to a marriage that was, temporarily at least, sexless.  For him to bring up the subject repeatedly, enough to overcome the listening and values hindrances of his therapist, felt humiliating. That's where therapists' leadership rather than follower stance on addressing sexual issues is vital. 

The upshot with Mr. and Mrs. Smith, I confess, was that I allowed too much lag time between identifying the two aspects of this vicious cycle and symmetrically addressing them both. 

Since my learning experience with the Smiths, I have been radically more attentive to sexual issues.  I aim to address sex with equal rapidity and weight as I address communication and other issues. At the same time, alas, I do think that my personal experience in the Smith case typifies the mistakes of too many female therapists.

A word to the wise in conclusion. 

If you are in therapy, and especially if your therapist is female, speak up.  Encourage your therapist to address immediately any sexual issues in your marriage that are a source of distress for either of you. 

If you are a therapist, don't wait for your clients to speak up.  Ask about sexual functioning, and if the answer to whether this arena has been a source of difficulties is yes, explore and treat these issues asap.

Lastly, I'd like to request your help.  What additional factors do you think might be sources of the tendency of marriage therapists to attend insufficiently to sexual issues in their couples?



Bancroft, J., Loftus, J., & Long, J. (2003). Distress about sex.  Archives of Sexual Behavior, 32, 193-211.

Basson, R. (2006). Sexual desire/arousal disorders in women. In S.Leiblum (Ed.), Principles and practice of sex therapy (4th ed.,pp. 25-53). New York: Guilford.

Keim, J., & Lappin, J. (2002). Structural-strategic marital therapy. In A. Gurman & N. Jacobson (Eds.), Clinical handbook of couple therapy (3rd ed., pp. 86-117). New York: Guilford.

LoPiccolo, J. & Friedman, J. (1988).  Broad-based treatment of low sexual desire. In S. Lieblum & R. Rosen (Eds.), Sexual desire disorders (pp.107-144). new York: Guilford.

McCarthy, B. (2008) Integrating Sex Therapy Interventions with Couple Therapy. J. Contemp Psychother 38:139-149.

Risen, C. (2003). Listening to sexual stories. In S. Levine, C. Risen & S. Althof (Eds.), Handbook of clinical sexuality for mental health professionals (pp. 3-19). New York: Brunner/Routledge.


(c) Susan Heitler, PhD
Source: (c) Susan Heitler, PhD

Susan Heitler, PhD, a Denver Clinical psychologist, is author of multiple publications including From Conflict to Resolution for therapists and The Power of Two for couples.  A graduate of Harvard and NYU, Dr. Heitler's most recent project is a marriage skills website,