What A Sex Therapist Does

Columns 4, Philip Emde (1)I found my way into sex therapy inadvertently. I didn’t set out to specialize in it, but after working with individuals and couples for many years and finding the conversation inevitably turning to sex and sexuality, I came to understand that there is a desperate need for counselors who are willing to talk openly and frankly about their clients most intimate thoughts, sexual practices, sexual fantasies.

Unfortunately many counselors feel uncomfortable or embarrassed and may change the subject, sometimes unconsciously, during a session when sex comes up. Growing up in a sex positive household, in which questions about sex were welcomed rather than shamed, talking about sex comes easily and naturally to me. Because I myself have thoroughly explored my own sexuality and sexual attitudes, rather than deflecting conversation, I am comfortable creating the space for others to discover their own.

Over the years, I familiarized myself with the writings of experts, attended lectures and professional trainings, joined associations and groups that supported openness and held sex positive attitudes, and thoroughly investigated my own assumptions, even biases about sex, eventually qualifying myself as a sex therapist.

There are many misconceptions about what a sex therapist does. Other than a ethical agreement regarding no physical contact, sex therapists practice using different approaches, from sex simple sex education to making suggestions about how to spice up their sex life.

Much of my work involves helping people understand their sexual desires, honor them, and create opportunities to express them. We spend a good deal of time exploring sexual beliefs, fantasies, past experience, sexual identity and gender issues within the wider context of the client’s psycho-sexual history. Not surprisingly, the largest group of clients who seeks sex therapy are trauma survivors. The sad reality is, many people with sexual conflicts have experienced some form of sexual abuse or assault in their lives which impacts their current sex life.

Our relationship to sex is far more complex than we assume. Most of us struggle with it at some point in our lives. And It’s especially difficult maintaining a satisfying and meaningful sex life with a partner with whom we are sharing our life.


To start, many people simply haven’t invested a lot of time exploring their sexuality. Men seem at a disadvantage here, because the first exposure most boys have to sex is often pornography; in the past, it may have been through the glossy naked photos of woman in dad’s Playboy, now it is pornography on the internet which overwhelming shows men with large every-ready penises, and woman willing to do whatever it takes to satisfy men’s need to get off. These images are misogynistic and cartoonish in their illustrations of what sex is and who is sexy. Girls, on the other hand, are more likely to discuss sex with peers and work a little harder to figure out their bodies and what feels good, because it is less straight forward than for boys. But, where woman may have a slight socialization advantage, we are at a severe disadvantage when it comes to being taught that our needs and wants actually matter. Consequently we grown ashamed, blame ourselves for having desires and fantasies, and eventually pathologize them.

Sex has a different meaning for everyone. For some, it is a way to create and foster intimacy. For others, sex can only happen after intimacy and trust have been established. Sometimes partners may not be on the same page. The difference in sexual approaches may lead to conflict that may be difficult to resolve and painful to discuss.

For most of us, sexual interest tends to ebb and flow based on many factors — psychological, biological, emotional and circumstantial. It’s not unusual for those in long-term relations to experience different levels of interest over the life of the relationship.

In Sexual Intelligence, Marty Klein suggests that we rely too much on the assumption that sex should be easy (our youthful hormones and the immaturity of our relationships inform this belief) and don’t make the adaptive changes necessary as we age or spend longer periods of time with a partner to keep sex satisfying. In Mating in Captivity by Esther Perel, the author writes that intimacy kills desire because it is hard to marry desire with the familiarity that occurs between partners whose life is so coalesced with your own. And in Your Brain on Sex, How Smarter Sex Can Change Your Life, of which I am a contributing author, Stanley Siegel, my father and editor of this magazine, suggests that most individuals are skipping the fundamental processes of learning about their true sexual selves and therefore do not have the ability to determine sexual compatibility with a partner before they make a long-term commitment.

To complicate matters, during sex, most of us are as much engaged in our private thoughts and fantasies as we are in what is actually occurring. We may be thinking about what our partner thinks about us; how we smell, feel, or taste, whether we are a good lover, if disappointed with their body, how do we measure up against other partners? And sometimes we may fantasize about a sexual act other than what we are involved with or even sex a different partner.

It’s a wonder any of us ever has sex. And some of us don’t.

Clients who seek therapy with me, generally fall into three type of categories. Those who are struggling because they have reached a sexual impasse with their partner (sex has slowed or stopped completely and one or both partners are concerned or unhappy about it); clients who feel as if they have some sort of sexual “dysfunction” such as premature ejaculation, inability to get or maintain an erection, a “low” libido, an inability to orgasm; and those whose lead lives in which their sexual practices or identity are considered somehow “fringe” or “nontraditional” — queer, poly, trans clients, practice kink or engage a fetish for whom their sexuality has lead to criticism and judgement. Because they have been forced to consider their differentness in relationship to sex, these clients are actually among the most sex savvy.

For some, therapy involves facilitating a safe dialogue around sex. Many have never talked openly and directly about their sexual desires. I focus conversation on what role sex plays in each partners history and psychology — what each of their preference are and how they come together and diverge in their interests. Unraveling partners sexual history can take time, especially if trust is not a natural part of the relationship or if it has been breeched by an affair or other event.

Sometime both partners may be inexperienced with sex or have different levels of experience. Beyond conversation, they may require encouragement to experiment, as well as guidance or specific strategies geared towards acting out their desires.

The most common issue couples present with is that sex has decreased or stopped in their relationship and this has caused an oppressive tension between them. The problem with less or no sex in a relationship for any given period of time is not that there is anything inherently wrong with it but that people apply meaning and significance to what they believe the change must represent. From this they can act out from a place of fear or rejection. They might withdraw, they might retaliate, they might it seek out sexual desire and validation from others. This kind of sexual impasse is both the best and the worst of sexual conflicts because in a lot of cases, sex was once good between partners and finding it again, with some open and compassionate conversation and ideas, is highly possible. But if this doesn’t happen the issue builds its own momentum and can poison a relationship, making it so toxic and damaging that partners ultimately part ways. The ways in which I help couples return to sex are varied. For some it is simply a matter a facilitating a safe dialog around it. For others it may look more like specific strategies geared towards pleasurable touch. In both cases it is a process of discovery. Of shedding light on what role sex plays in each partners being and learning where preferences come together and diverge in a respectful way. It can take time, depending on where the couple is starting from and if they are trying to recover from something such as a wound in trust, but it can happen.

The coming back together. And it is truly wonderful.

In some cases, partners are sexually incompatible and unable to navigate a sex life that works for both. While it can be a matter of differing sexual preferences, more often a satisfying sex life can’t be achieved because the underlying issue is more about power and control than it is about sexual differences. Rather than functioning as a team in which both partner’s feelings and desires are honored, one or both partners are caught up in thinking, “how can I get my partner to do it my way?”

I recently counseled a couple in which one partner wanted an open or poly relationship and the other believed strongly in monogamy. Frank conversations could not resolve the issue. Both decided their difference was intolerable; they made the decision to part. in another case, one partner had a strong desire to act out BDSM fantasies, while the other, a strong distaste for bondage. Detailed conversations about sex, reading books, and watching video’s provided an “education” about BDSM, that helped the reluctant partner to understand the structure, safety, and communication that went into such play. Her education freed her to experiment which over time, she found both liberating and satisfying. The kinky partner on the other hand, was asked to make some compromises of his own about certain practices that were off-limits.

Typically when a client comes to me with a self-diagnosed sexual dysfunctions, I first direct them to a medical doctor to rule out very real physical complications. When a difficult cannot be explained medically, there may be an emotional trauma at its root.

Sexual trauma can impact survivors in a multitude of ways both internally (desires, fantasies) and externally (physical response cycles and sexual practices). Its effects can crop back up even when we believe we’ve “put it behind” us. A psychological defense such as detachment or dissociation that served to protect against overwhelming emotions in the past, gets triggered automatically in sexual situations in the present. Before we know it, we have lost our erection, experience dryness or pain, or lost interest in sex altogether.

Survivors often have a long journey, and their partner’s is challenging as well. I coach partners to be patient — to maintain a solid sense of self, to learn what their partners triggers are but to not take their partner’s triggered reactions personally when they are inadvertently happened upon. With the right attitude, it is a precious opportunity for growth. “Healing Sex; A Mind Body Approach to Healing Sexual Trauma” by Staci Haines does a beautiful job describing this.

For those who have not experienced sexual trauma, I see a vicious cycle at the root of sexual dysfunction. One incident of premature ejaculation or a lost erection, for instance, creates such fear, anxiety and self-doubt that the we become consumed with the thought that our body will not cooperate, turning into our enemy. As a result we might develop performance anxiety before sex or avoid it altogether.

There are a few “quick fix” solutions to delay ejaculation or prolong erections that I relay to clients that often break the cycle of failure, but the longest term benefit comes when we practice mindfulness; when we learn to be in the present moment by focusing on our breath. Typically, when we have conflict over sex we hold our breath. This sends a message to our brain to be on alert, a message in conflict with what is needed in order to let go and surrender to a sexual experience. By opening our breath, we can return to the present and allow the experience to flow without expectation.

For those clients with sexual interests or identities far outside the norm, therapy must have a strong element of support and acceptance because of the effects discrimination and oppression may have had on them. Many of these clients have already developed a strong sense of self awareness as well as the courage necessary to forge their own path where there haven’t been maps to follow. In forming a polyamorous or open relationships, therapy can now help them learn to better manage complicated personal dynamics, establish rules to navigate jealousy, rivalry, loyalty and respect, and develop communication skills along with a high level of personal responsibility and accountability.

Think back, for a moment, to when you first learned about sex. Was it an awkward, brief or cautionary conversation with your parents, the preachings of your church, a sex education class at school that warned about pregnancy and STD’s, the media? Few people have positive or open-minded introductions to the world of sex. With a lack of information, misassumptions, myths and half truths fill in the gaps of all that we do not know.

Too many of us feel hurt, embarrassment, and shame because of misconceptions about what it means to be sexually healthy. When it comes to sex, there is no “normal”. Sexual fantasies and practices are incredibly diverse and original, despite what we are led to believe. So long as sex is consensual — as asking a partner if they want to proceed, or as complex as specific arrangements made with multiple partners — sex can be meaningful and gratifying.

Our sexual desires have origins that stretch far back into our earliest experiences, before we even knew what sex was. Many of the clients I worked with are afraid to share their fantasies and desires because they worry about what their partner may think of them. The common fantasy of dominating or of being dominated, for instance, may be in direct opposition for a desire for true equality in all other aspects of a relationship and therefore may never discussed. It’s important that we remember, that when we deny, repress or burry our sexual fantasies we grow alienated from who we truly are. Knowing and honoring our desires is essential to our sense of well-being. We always have the choice to limit their expression to the bedroom or design a life style around them depending on the depth of our needs and the authenticity of the relationship we create with a partner.

I deeply believe in the power of sex therapy to repair misconceptions, heal sexual wounds and open the doors to more meaningful, creative, and gratifying sex.

I feel grateful every day that this profession found me. I am honored to have the opportunity to join many like-minded others in creating a more accepting and positive view of sex so that our children may avoid the conflict and suffering inflicted by repressive ideologies, whether they originate in religious fundamentalism or the field of psychology.

About Alyssa Siegel 29 Articles
Alyssa Siegel is a Licensed Professional Counselor in Portland, Oregon. She earned her MS in Counseling and her BA in Psychology and is a member of The Oregon Board of Licensed Professional Counselors, The American Counseling Association, The National Board of Certified Counselors, The National Coalition for Sexual Freedom, and The Society for the Scientific Study of Sexuality. She works with individuals and couples and specializes in relationships, sexuality, and women's identity development. Alyssa is a contributing author to the book "Your Brain On Sex, How Smarter Sex Can Change Your Life". For more information please visit PortlandSexandRelationshipTherapy.com.
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