Sex Therapy

Originally published on April 28, 2020 Last updated on July 14, 2020

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Sex therapy is an effective way to achieve satisfaction in your sex life. Seeking consultation with a credentialed and knowledgeable provider can help both couples and individuals address common sexual concerns. Typical rates for a certified sex therapist are on the upper end of private pay therapy rates in your area, and treatment can last anywhere from a few sessions to a few years, depending on the issues being addressed.

What is Sex Therapy?

Sex therapy is an extension of traditional talk therapy that affirms the fundamental value of sexuality as an inherent, essential, and beneficial dimension of being human. Sex therapists use a non-pathologizing approach, emphasizing sexual freedom of thoughts, feelings, fantasies and healthy modes of sexual activity.

Sex therapy allows clients to consider (often for the first time) what their sexual experience has been like over their lifespan, what their sexual experience is currently like and what priorities they have for sexual expression in the future. Sex therapy provides an opportunity to be more intentional in an area of life that is crucial to health and well being.

Therapeutic goals are established by the client in areas of their sex life that cause them difficulty or dissatisfaction, whether that be through internal thought patterns or outward expression. These goals are often addressed in tandem with other therapeutic topics typical to counseling, such as partner relational issues, conflict, stress, trauma, anxiety or depression.

Sex therapy will never include sexual contact with your therapist. Sex therapy is NOT sex surrogacy or a euphemism for sex work of any kind.

What Can Sex Therapy Help With?

Sex therapy addresses a wide array of sexual concerns that impact both individuals and relationships. Topics include issues with arousal, frequency, sexual pain, difficulty achieving orgasm, out of control sexual behavior, physiological shifts after childbirth or menopause and changes in the sexual dynamic of a couple over time.

When sexual issues cause distress, a sex therapist can help discern what physiological factors to rule out (or refer to other providers for treatment) and what psychological factors can be examined and addressed. Sex therapists typically work closely with general practitioners, psychiatrists, physical therapists, gynecologists and urologists so that a coordination of care can provide the best treatment.

Common stressors and phase-of-life shifts tend to precipitate the issues presented in a sex therapist’s office. Knowing what these factors are can be helpful in deciding whether sex therapy is the right choice for you or for your relationship.

Stress-inducing factors to look out for include:

Anxiety
Depression
First sexual experience
History of trauma, sexual or otherwise
History of sex negativity or shame around sex
Gender fluidity or transition
Lack of education/information about healthy sexual practices
STIs
Disability/illness/medical issues
Marriage/cohabitation
Childbirth/child rearing
Stressful job requirements
Divorce
Change in sexual partner(s)
Aging/perimenopause/menopause

Sex therapy can help mitigate how much impact these factors have on a satisfying sex life. A sex therapist will help identify what the issue is, what physiological components to address, what structural changes can be made and what psychological processes are contributing to the problem.

Topics that clients report experiencing distress about include:

Not having enough sex, as a couple or individually
Wanting sex more or less frequently than their partner(s)
Lack of interest in sex
Pain or discomfort when having sex
Inability to get aroused or stay aroused
Inability to have an orgasm
Having an orgasm too quickly
Misalignment between gender identity and biological sex/genitalia
Having intrusive or disturbing thoughts about sex
Masturbating or having sex compulsively
Desire to expand the range of sexual experience, as a couple or individually

In addition to these common problems, clients may have received a medical diagnosis from a doctor or believe a medical diagnosis may be relevant to their situation.

Diagnosable psychological and physiological issues that are relevant to treatment by a sex therapist include:¹

Premature Ejaculation/Early Ejaculation
Delayed Ejaculation
Erectile Disorder/Erectile Dysfunction
Vestibulodynia/Genito-Pelvic Pain Disorder
Anorgasmia/Female Orgasmic Disorder
Male Hypoactive Sexual Desire Disorder
Female Sexual Arousal Disorder
Gender Dysphoria
Substance/Medication Induced Sexual Dysfunction
Unspecified Sexual Dysfunction

Common Techniques & Approaches Utilized in Sex Therapy

Sex therapists come from a wide range of backgrounds and employ techniques unique to their own therapeutic style and approach. However, there are a few standard components to sex therapy that are widely regarded for their efficacy and which you are likely to experience in treatment with most sex therapists.

Sex therapists are trained to employ the four levels of the PLISSIT Model in their assessment and treatment practices. Developed in 1976 by Jack Annon, the PLISSIT model was designed to ensure that clients receive appropriate interventions for the issues they present with.²

Level One: “Permission-giving,” or creating a comfortable environment in which the client feels permission to share vulnerable details of their sexual selves without fear of judgment.
Level Two: “Limited information” wherein a therapist provides psycho-education in the areas most appropriate to a client’s concerns, being careful not to overwhelm the client with information that they are not yet ready for or that is not applicable to their circumstance.
Level Three: “Specific suggestions” in which a therapist offers tools to try between sessions that address the client’s therapeutic issues.
Level Four: “Intensive therapy” in which the therapist develops with the client a long term strategy of individual, group or couples therapy to process and address underlying issues.

Mindfulness

One of the “specific suggestions” that a sex therapist may make is Mindfulness, a category of tools which has been studied and proven to be effective when used to address sexual dysfunction. Mindfulness as applied to sex therapy, in the words of Lori Brotto PhD, is “the practice of noticing what is happening inside us and of being kind to ourselves, even when we struggle to do so.”³ Mindfulness improves nonjudgmental attention, one of the precursors to satisfying sex.

Sensate Focus

One type of mindfulness technique, if you are in sex therapy with a partner or partners, is Sensate Focus. Sensate focus exercises are a technique developed in the 1960s by William Masters and Virginia Johnson, two pioneers in the field of sex therapy. Sensate focus exercises are used to reduce anxiety around sexual interactions by slowing down the process of intimacy.⁴

Partners are directed to incrementally explore basic touch sensations over a series of weeks, dismantling the habitual ways in which they have engaged in physical touch and sexual interaction in the past. The goal is to cultivate awareness around touch and arousal in order to foster a positive feedback loop that increases desire and connection.

Evaluate Intimate Dance

Another approach commonly utilized in partnered sex therapy is assessment of the Intimate Dance that partners engage in around sex. This includes how partners initiate sex, who tends to have a higher desire for sex, and what structural factors in the clients’ lives have contributed to an intimate dance that is no longer satisfying to one or more partners.

Dual Control Model

A sex therapist will often employ the Dual Control Model⁵ for sexuality in assessing a relationship’s intimate dance. The dual control model posits that the context in which our sexuality exists matters. Not only do we need to take a look at what turns us on and the mechanisms of our sexual excitation system, but also what turns us off, or our sexual inhibition system. Utilizing the lens of the dual control model, a sex therapist will help a couple make crucial changes in their intimate dance in order to reach a connected and contented equilibrium in sexual interactions.

Sex Therapy Examples

There are many reasons why an individual or a couple would seek out sex therapy. This section elaborates on some of the more common examples for why clients come to see a sex therapist and what the trajectory of their therapy might look like.

Sex Therapy Example #1

Angela and Tony have been married for 36 years. They have a loving partnership, but their sex life has dwindled to an infrequent pattern of sex once every 2 months. Their interactions tend to be brief and awkward. Tony has also begun to have difficulty maintaining an erection. If penetrative sex is unsuccessful, they usually stop their interaction. Both Tony and Angela would like to have more frequent and more satisfying sex. Their sex therapist refers Tony to a urologist specializing in sexual medicine to assess for any underlying medical issues for his erectile dysfunction. She then assesses the habits the couple has in initiating sex and asks them to dismantle their preconceived notions of what sex should look like. She has them create more space in their lives for sensual touch and quality time. She asks them to follow the Sensate Focus model to build a new kind of intimacy. After 8 months Angela and Tony report a higher frequency of sexual interactions and a higher satisfaction in their sex life. Tony is more able to maintain an erection and the couple also has an expanded sexual repertoire for when his erection dissipates.

Sex Therapy Example #2

Paul and Jessica have been in a relationship for 3 years. Their sex is not able to be penetrative or involve direct touch to Jessica’s vulva due to pain she experiences when touched. Jessica has never had a physically pleasurable experience or orgasm involving penetrative sex. Their sex therapist assesses Jessica for a history of sexual trauma. She then refers Jessica to a gynecologist and physical therapist specializing in pelvic pain. Jessica is diagnosed with vestibulodynia and is given dilators in conjunction with regular physical therapy. Their sex therapist addresses the anxiety cycle in the couple that has evolved as a repercussion of Jessica’s pain symptoms. She assigns mindfulness work for the couple to explore in order to reduce the anxiety and increase pleasure. After 14 months Jessica has made significant progress in being able to receive touch pleasurably from Paul and they are working toward penetrative sex.

Sex Therapy Example #3

Sam is 27 years old and has never had a sexual relationship. He watches porn and masturbates 1-3 times a day and sometimes is late to work or misses social activities as a result. The frequency that Sam masturbates has escalated over the last year and he worries that his behavior has become compulsive and that he doesn’t have control over his life. Sam would like to limit the amount of focus he is giving to masturbation and would also like to explore more meaningful relationships. His sex therapist works with Sam to understand why his behavior has increased in frequency and feels outside his control. She explores how his childhood and family background may have made it difficult to form satisfying relationships. She helps Sam establish therapeutic goals for modified behavior and cultivate mindfulness practices to achieve those goals. After 11 months Sam has reduced the frequency of his masturbation. He feels less anxious, more confident and more in control of his own life. He is beginning to date someone he has developed feelings for and has experienced partnered sex for the first time.

Cost of Sex Therapy

Most sex therapists see individual clients for 45-60 minute sessions at rates between $120-$180 and relationships/couples for 75-90 minute sessions at rates between $190-$310. These rates may vary widely based on the availability of certified sex therapists in your area and on general mental health costs in your state.

You may be wondering if your insurance benefits can cover some or all of the cost of sex therapy. Insurance companies typically only offer mental health benefits when there is a diagnosable issue. Some sex therapy topics do indicate a billable diagnosis that most insurance companies will accept, such as female orgasmic disorder or delayed ejaculation. If that diagnosis is the primary reason for seeking therapy, your insurance company may cover the cost.

When seeking sex therapy as an individual, there may be a concurrent or contributing diagnosis, such as an anxiety disorder, which can be billed to insurance companies. In that instance, even if the sexual issues you are presenting with are not billable, your insurance provider may cover therapy.

One other factor to consider in seeking insurance coverage for sex therapy is whether you are required by your insurance provider to see an in-network practitioner. Many insurance companies do not have a certified sex therapist on their panel of providers. If that is the case for your geographical area, you may have only out-of-network reimbursement options.

Alternatives for payment include utilizing your HSA or FSA accounts through your employee benefits, which typically can be used to see any mental health practitioner, including a certified sex therapist.

How to Find a Sex Therapist

When seeking a sex therapist you want to make sure to find an adequately trained and certified provider. “Sex therapy” and “sex therapist” are not protected terms under any current state laws. What that means is that anyone can call themselves a sex therapist without having had the training to do so.

Fortunately, the American Association of Sex Counselors, Educators and Therapists (AASECT) is a credible body of oversight which has been the gold standard in certification for sex therapy since 1967. With its history of impeccable standards for training, experience and ethical behavior, AASECT is increasingly recognized as the guardian of professional standards in sexual health. Sex therapists may receive their education and supervision at a number of universities and sex therapy training institutions across the globe. If the training they receive meets the rigorous requirements of AASECT, they can become a Certified Sex Therapist (CST) in addition to being a licensed therapist in their respective field.

In order to receive the best care, always look for an AASECT Certified Sex Therapist (CST).

The best way to find a certified sex therapist in your area is to visit www.aasect.org.

What to Expect at Your First Appointment

Your initial session with a sex therapist will primarily entail information gathering and creating a treatment plan. The therapist will inquire about what brings you to therapy, what changes you would like to make in your life, and what measurable goals you would like to achieve.

Your therapist will also ask for a detailed history of your current and past relationships and sexual practices. Your therapist is also likely to inquire about your mental health history, any medications, your current and past substance use, your childhood and family of origin and any history of trauma. Therapy is most effective when you are able to be honest and forthcoming about the details of your life and what brought you into the therapist’s office. However, you should never feel pressure to answer a question you are not ready to or are uncomfortable with.

Sex therapy and all forms of talk therapy are most effective if you feel a strong therapeutic alliance, or professional rapport, with your therapist. Your initial session is a time to assess whether this therapist is the right fit for you. Make sure that you utilize this time to ask any necessary questions of your provider in order to make an informed decision about proceeding with treatment.

Is Sex Therapy Effective?

Based on the issues you present with in therapy and how entrenched they have become, therapy can last anywhere from a few sessions to a few years in order to see the results you are hoping for. Much of that success depends on how frequently you attend therapy, how motivated you are for change and how active you are between sessions in implementing the tools assigned by your therapist. Results may also depend on coordination of care with other medical providers such as primary care physicians, gynecologists, urologists, psychiatrists or physical therapists.

Although many presenting issues in sex therapy have a physiological component and can sometimes be treated with medication or other medical intervention, optimal outcomes occur when an appropriately trained therapist addresses psychological issues concurrently with medical professionals. A consensus statement from the 2015 International Consultation on Sexual Medicine recommended that both women and men with sexual dysfunction should be offered psychosocial evaluation (sex therapy) in addition to any medical intervention they receive in order to achieve the most positive outcome for treatment.⁶

While studies in the field of sex therapy are somewhat limited, the studies that have been conducted have largely shown promising results. In a study conducted in 2017, participants in mindfulness-based sex therapy reported significant improvements in sexual desire, sexual function and sex-related distress.⁷ A meta-analysis of the study found evidence that mindfulness-based sex therapy was effective for treating female sexual dysfunction and held promise for treating men with situational erectile dysfunction.⁸

How Is Sex Therapy Different Than Other Therapy Options?

Although licensure requirements for becoming a general mental health practitioner vary between different states and degree programs, typically the amount of training a clinician receives in regard to human sexuality is minimal or nonexistent. In fact, clinicians may never treat sex-specific issues during their training process and still become fully licensed professionals. As a consequence, many therapists do not broach the topic of sex with their clients or do so only in a cursory manner. Even if a therapist is comfortable with and competent in discussing sexual issues, they may lack the training necessary to assess and address sexual concerns in a meaningful way.

Sex therapists differ from other talk therapists in the amount of training they have had in sex-specific issues and in the amount of exposure they have had to a broad range of sex specific therapeutic topics. In addition to the licensure requirements for becoming an individual counselor or a marriage and family therapist, sex therapists receive an additional 18-24 months of rigorous training, including 300 hours of sex-specific supervision.⁹

In order to complete certification as a sex therapist, clinicians must have academic coursework in the following core competencies:

- Ethics and ethical behavior.
- Developmental sexuality from a bio-psycho-social perspective across the life course
- Socio-cultural, familial factors (e.g., ethnicity, culture, religion, spirituality, socioeconomic status, family values), in relation to sexual values and behaviors
- Issues related to sexual orientation and/or gender identity: heterosexuality; issues and themes impacting lesbian, gay, bisexual, pansexual, asexual people; gender identity and expression
- Intimacy skills (e.g., social, emotional, sexual), intimate relationships, interpersonal relationships and family dynamics
- Diversities in sexual expression and lifestyles, including, but not limited to polyamory, swinging, BDSM and tantra
- Sexual and reproductive anatomy/physiology
- Health/medical factors that may influence sexuality, including, but not limited to, illness, disability, drugs, mental health, conception, pregnancy, childbirth & pregnancy termination, contraception, fertility, HIV/AIDS, sexually transmitted infection, other infections, sexual trauma, injury and safer sex practices
- Range of sexual functioning and behavior, from optimal to problematic, including, but not limited to, common issues such as: desire discrepancy, lack of desire, difficulty achieving or maintaining arousal, sexual pain, penetration problems and difficulty with orgasm
- Sexual exploitation, including sexual abuse, sexual harassment and sexual assault
- Cyber sexuality and social media
- Substance use/abuse and sexuality
- Pleasure enhancement skills
- Learning theory and its application
- Knowledge of professional communication skills used with clients, students and colleagues
- History of the discipline of sex research, theory, education, counseling and therapy

History of Sex Therapy

Modern sex therapy is the practice of improving sexual function and satisfaction through specialized talk therapy with a knowledgeable provider.

The development of modern sex therapy was influenced by sexologist Alfred Kinsey and the research his institute conducted in the first half of the 20th century on human sexuality. The Kinsey Institute is most known for a series of books colloquially known as the “Kinsey Reports,” which revealed qualitative analysis unprecedented in the field of sexology, as well as the “Kinsey Scale,” which presented homo and hetero sexuality on a spectrum. The Kinsey Institute has evolved and today continues to perform research valuable to the field of sex therapy.¹⁰

Modern sex therapy was also impacted by the research that William Masters and Virginia Johnson conducted in the second half of the 20th century. Masters and Johnson are most known for observing volunteers enact the human sexual response cycle in a laboratory and for developing the four-stage model of sexual response (excitation, plateau, orgasm and resolution). Masters and Johnson also developed protocol for working with couples experiencing sexual dysfunction and they had a higher rate of success than previous attempts to treat sexual dysfunction through talk therapy.¹⁰

As sexology continued to evolve and sex became a more publicly discussed topic, sex therapy coalesced into a cohesive field in the 1960s. The American Association of Sexuality Educators Counselors and Therapists (AASECT) was founded in 1967. AASECT developed standards of care for sex therapy and is the predominant certifying body for sex therapists.⁹

Medical interventions for treating sexual dysfunction that developed in the 1980s and later, such as the discovery of sildenafil (Viagra) to treat Erectile Disorder, also became part of the coordination of care between providers that modern sex therapists utilize when mapping an appropriate treatment plan.

AASECT membership has grown exponentially in the past decade and sex therapy continues to be a fast-growing field. This growth can be attributed in part to a cultural shift wherein younger generations do not believe they have to settle for a mediocre sex life and that sex and sexuality are a central component to health and well being.