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When It Comes to Sex and Therapy, Do Your Research First

Not all therapists are adequately trained in sex.

I want to discuss an example that is admittedly stereotypically gendered. Bear with me. People of any gender may identify with this.

For decades, when a couples therapist was working with a heterosexual couple and the issue was sexual in nature where the woman did not want to have sex when the man did, the couples therapist was trained to tell the woman “Don’t have sex when you don’t want to.” So the woman didn’t. She had permission to say no with the support and validation of the couples therapist, the "expert," and without guilt. And what this did was it led to couples becoming engaged in power struggles over sex—whereby the woman was the sexual gatekeeper and controlled when they had sex. The man often felt powerless and then maybe resentful, angry, or emasculated. Sounds just like our patriarchal culture at large, doesn't it?

All of this was really not sexy. And too black and white. It also brought about the notion of “choreplay” (“See, honey? I did the dishes! Now can we have sex?”)—where sex was something to barter. Ugh. Again, really not sexy. And again a sign that capitalism and commodification of sex had seeped into the relationship.

I suspect there are couples therapists out there who are still working this way. This approach was and is a mistake. That suggestion was not informed by the study of sexuality and relationships; it was only informed by the gendered study of couples and possibly an unconscious belief that the woman was the victim who needed to be protected. And if you know anything about my profession, it is that most therapists lack meaningful education and training in sexuality.

Now look, I understand where this suggestion came from. It came from a belief system that women are frequently pressured by men to have sex. That intervention was addressing the matter of consent. And yes absolutely consent is a necessary aspect of partnered sex. But consent is not the only issue that plays into a person's decision to engage sexually with a partner. Our culture is taking a long hard look at the role of consent these days and it’s important and I am glad we are talking about it. But there’s so much more to sex than just consent. More importantly, this intervention ignores the many, many possible reasons why a woman might not want to have sex with her partner.

Is the therapist pondering why she is saying no? This is the key question that is often not asked: why exactly is she saying no? Fatigue and disinterest are common reasons I hear from women in this very situation. Does she have an undiagnosed medical problem? An undiagnosed mental health issue? Is sexual trauma in her past? Do stress or her body image play a role in her sex drive? Is her lower libido due to a medication’s side effects? Are there latent relationship dynamics happening like normal marital hatred or Gottman’s four horsemen or resentment that she and/or the couple is struggling to talk about or work through? What about her beliefs about sex—does she believe sex is her marital duty or mainly for her male partner and his pleasure? Does she ever experience sexual pain? Does she know what to do to bring herself to orgasm? Does she orgasm regularly during sex? What about her sexual shame? And what does she think and feel about the sex she and her partner do have? Does the sex her partner likes to have ever violate her dignity or squick her but she does not know how to communicate this? Even if it’s not that extreme, is the sex they have just not great for her? Are they talking about any of these issues?

As you can see, there are a lot of factors that go into whether a person decides to have sex. This is the other important factor here that often gets ignored: motivation. Making this relational impasse only about consent, a yes or a no, is too simplistic and does not address the many, many layers involved in the human sexual experience. I have worked with many individuals and couples over the years who tell me their previous therapist(s) never asked the questions I ask or address the issues I address.

So what is the takeaway? Not every couples therapist is a sex therapist. When it comes to sexual issues and therapy, please make the effort to find yourself a certified sex therapist. There are only about 500 of us worldwide so it can seem daunting. However, it being the time of COVID, most of us are doing teletherapy so you are no longer confined to finding a therapist in your area. Good luck.

© 2020 Diane Gleim

To find a therapist, visit the Psychology Today Therapy Directory.