Good Housekeeping:

SEX THERAPY HELPS
MANY MARRIAGES:
CAN IT HELP YOURS?

By Michael Castleman

Diane and Alan, both 41, had two sons and had been married 12 years when they first consulted Louanne Cole Weston, Ph.D., a sex therapist in Fair Oaks, California, near Sacramento. They both loved each other, and insisted they had a good marriage. But, they explained, they also had a problem: Alan wanted sex more often than Diane did--twice as often. She was perfectly happy making love once a week, and insisted that most of her friends did it less. Alan wanted sex twice a week or more. “They had what sex therapists call a ‘desire discrepancy,’” Weston explains. “It’s one of the leading reasons couples consult sex therapists.”

Alan had nsisted the couple see a sex therapist. Diane consented but reluctantly, fearing that Weston would take her husband’s side and urge her to have sex more often. Weston did no such thing. She explained that they had a common problem, that there was no “right,” “wrong,” or “normal” sexual frequency, and that she would do her best to help them solve their problem by reaching a workable compromise that respected both of their feelings. Diane felt reassured.

During weekly sessions that lasted 18 months, Alan and Diane discussed their sex life--and the rest of their lives--with Weston. It turned out that their problem involved more than just a desire discrepancy. Diane came from a family with fundamentalist religious beliefs. She was raised to view sex as dirty, especially oral sex, which she was willing to perform, but refused to receive, much to Alan’s chagrin. He very much wanted to give his wife this intimate pleasure, and felt rejected by her refusal. Alan had other feelings of rejection as well. In addition to his wife's comparative lack of libido, Diane was also not as non-sexually affectionate as he would have liked. He wanted more hugging, hand-holding, and cuddling than she did, and felt hurt when she pushed him away. Alan was a successful contractor, but did not make as much money as Diane, a real estate broker. She wanted to work less and spend more time as a mom. She nagged Alan to make more money, which made him feel insecure, angry, and emotionally needy. When he felt needy, he want the validation and reassurance that sex provided him, which contributed to the strain around their desire discrepancy.

THE NEWEST MENTAL HEALTH PROFESSION

Among the mental health professions (psychology, psychiatry, social work, psychiatric nursing, and marriage--or couples or relationship--counseling), sex therapy is comparatively new, explains Bloomfield Hills, Michigan, sex therapist Dennis Sugrue, Ph.D., a clinical associate professor of psychiatry at the University of Michigan Medical Center in Ann Arbor, and president of the American Association of Sex Educators, Counselors, and Therapists (AASECT). Sex therapy was born in the 1960s, when pioneering sex researchers William Masters, M.D., and Virginia Johnson showed that a combination of three approaches--basic sex education, whole-body sensuality (caressing everything, not just the breasts and genitals), and specific sexual techniques--could resolve a surprisingly large proportion of sex problems. Using the Masters-and-Johnson model and subsequent refinements, many women who had never had orgasms, a condition medically known as “pre-orgasmia,” learned to enjoy them, and many men learned ejaculatory control and restored lost or flagging erections.

This was revolutionary. At the time of Masters’ and Johnson’s original work, marriage counselors generally believed that once traditional talk therapy improved troubled relationships, sexual improvement automatically followed. “Marriage counselors didn’t focus on sex,” Weston explains. “Masters and Johnson showed that by zeroing in on it, sex therapy could usually improve sexual functioning, often without much focus on the relationship.”

Sex therapy also caused considerable controversy. “There was a tendency,” Weston explains, “for early sex therapists to say the opposite of what the marriage counselors had been saying--that once the sex problems were resolved, the marriage would automatically improve.” In reaction, marriage counselors accused sex therapists of a mechanical, “cookbook” approach, and of under-emphasizing the many relationship issues that contribute to sex problems and sexual fulfillment.

Fortunately for today’s couples, this controversy is history. Relationship counselors and sex therapists have buried the hatchet. “These days,” says Michael Plaut, Ph.D., an associate professor of psychiatry at the University of Maryland School of Medicine and president of the Society for Sex Therapy and Research (SSTAR), “sex therapy almost always involves relationship therapy as well. Some sex problems are independent of the relationship, for example, rapid, uncontrolled (“premature”) ejaculation in young men. But for most sex problems, you have to deal with both the relationship and the sex.”

Weston agrees: “I wouldn’t say that sex therapy and relationship therapy have merged into one. I still call myself a sex therapist because I specialize in sex problems. But in addition to my sex therapy credentials, I’m also a licensed marriage and family therapist (MFT).”

So, what’s the difference between sex therapy and relationship counseling? “Couple counseling,” says Janet Hyde, Ph.D., a professor of psycology at the University of Wisconsin in Madison, and current president of the Society for the Scientific Study of Sex (SSSS), “ often deals with issues of communication and control--how the couple makes decisions and resolves differences of opinion. It may not deal with sex. But when couples consult a sex therapist, sex is definitely on the agenda.”

In addition, marital therapists and sex therapists have different training. Currently, the gold standard of sex therapy is AASECT certification. “To earn it,” Sugure says, “you must start out as a licensed mental health professional. You must practice psychotherapy for at least 1,000 hours a year for several years. Then you must complete additional academic reqirements in all aspects of human sexuality, followed by 100 hours of sex therapy closely monitored by an AASECT-approved supervisor, and then 500 hours of sex therapy practice.” Currently, there are approximately 500 AASECT-certified sex therapists in the U.S.

Of course, every marriage has sexual issues: disagreements over sexual frequency, the pace of lovemaking (extended or “quickies”), the mix of whole-body and genital caresses, types of sexual expression (e.g. oral sex, and swallowing semen, etc.) and other issues (undressing for each other, lights on or off, use of sex toys or x-rated media, etc.). How do you know if your disagreements are serious enough to warrant sex therapy? “It’s subjective,” Hyde says. “People come in when they feel stuck, troubled by a persistent problem they can’t resolve on their own.”

PROBLEMS SEX THERAPY CAN HELP

“The first step toward resolving sex problems,” Plaut explains, “is to consult your family doctor, and maybe a urologist or gynecologist. Many sex problems have medical elements. Unfortunately, many doctors are not very comfortable dealing with sexual issues. You may have to shop around for a physician who is. If medical treatment doesn’t resolve things to your satisfaction, then it’s time to consider sex therapy, especially if you experience a persistent loss of libido, difficulty becoming aroused, problems reaching orgasm, or painful sex.”

In the early days, sex therapists counseled many women unable to have orgasms, other women with vaginal muscle spasms that prevented intercourse (vaginismus), and many men who lacked ejaculatory control. Sex therapists still treat these problems, but pre-orgasmia, vaginismus, and premature ejaculation can often be resolved by reading self-help books (see Box).

In addition to the problems that lend themselves to self-help, the issues couples typically bring to sex therapists include:

* Low or diminished sexual desire. There may be a medical cause, for example, certain antidepressants (notably, the Prozac family of drugs), or low blood levels of testosterone--even in women. Testosterone is the "male" sex hormone, Sugrue explains, but both sexes have it, and it’s responsible for sex drive in both men and women. Relationship problems and other life stresses may also play a role in loss of libido.

* Desire discrepancies. Both spouses have libidos in the normal range, but, like Alan and Diane, one wants sex more often than the other. Relationship problems and other life stresses may be involved, but in many cases, the people simply have different levels of desire. The stereotype is that compared with women, men want sex more frequently. But that’s not necessarily so. “I’ve seen plenty of couples,” Weston says, “where the woman wanted sex more often than the man.”

* Erection problems. Many factors can contribute to erection impairment: illnesses (among them: heart disease, diabetes, and chronic pain), drugs (notably: alcohol, smoking, antidepressants, narcotics, and certain blood pressure medications), prostate surgery, and relationship problems or other life stresses. When the erection pill, Viagra, was released a few years ago, some sex therapists feared a loss of business. In fact, Hyde says, Viagra has been a boon to sex therapy: “It put erection impairment in the news. You had Bob Dole [the former Republican Presidential candidate] on TV saying it helped treat his impotence. That gave many men permission to admit they had the problem and get help. The research shows that Viagra works best when combined with the kind of talk therapy sex therapists provide.”

* Sexual aversion. People with this condition not only have no libido, they feel a deep visceral fear of sex, and may no know why. Frequently, the cause is past sexual trauma, for example, incest, rape, or sexual abuse.

* Pain on intercourse. In addition to vaginismus, women’s pain may be caused by: endometriosis, reproductive tract infections, anxiety, relationship stress, an unusually low pain threshold, and a history of sexual trauma.

SEX THERAPY WORKS

Sex therapists claim considerable success treating all these problems. “In a cooperative relationship where both people are equally committed to working together,” Plaut explains, “sex problems usually improve with therapy.”

However, sex therapists agree that one of the most treatment-resistant problems is desire discrepancy, where one person has much less libido than the other. “Some of my most personally satisfying cases have involved desire discrepancies,” Weston explains, “so there’s certainly hope for couples with this problem. But sometimes I see couples who simply refuse to compromise, who fear intimacy, and prefer fighting to harmony. Then things are much less likely to work out.”

Studies of sex therapy outcomes support the therapists’ claims. In a 1997 report published in the Journal of Sex and Marital Therapy, researchers at University of Pennsylvania School of Medicine in Philadelphia tracked 365 married couples who sought sex therapy for a variety of problems. In two-thirds of them (65 percent), sex therapy resolved the problem. Treatment outcome was unaffected by the specific problem, the gender of the person with the symptom, or that person’s history of sexual trauma. Among couples who did not respond to sex therapy, the reason often had to do with the presence of an illness, for example, heart disease or diabetes, both of which can impair sexual functioning. The researchers concluded, “Sex therapy is effective in [the] real world.”

However, this study involved cooperative couples, both of whom participated in the therapy. Sometimes, one spouse refuses to consult a therapist. Then what? “Even when one person has the symptom or complaint,” Hyde explains, “the couple has the problem. The solution involves both of them. Sex therapy is not some awful experience. The spouse who wants it should appeal to the other saying it’s likely to improve their sex and strengthen their relationship, which helps both of them.”

If one one spouse still flatly refuses, the one who wants sex therapy can be seen solo. “It’s usually not a good sign,” Plaut says. “It makes you wonder about the level of trust and cooperation in the relationship.”

But sometimes, solo sex therapy helps. “I always prefer to see couples,” Weston explains, “but if only one is willing to come in, that person can still get information, explore feelings, and take home new information that might help or eventually persuade the other to come in.”

HOW LONG IT TAKES. WHAT IT COSTS.

For most issues, sex therapy typically takes four to six months of weekly, one-hour sessions, often with “homework,” for example, conversations to gain experience in new communication skills, or sensual assignments in bed to practice new lovemaking techniques. “My shortest course of therapy,” Plaut recalls, “took just seven sessions. My longest is still going on after three years. But on average, sex therapy takes four to six months, 16 to 24 sessions.”

Depending on location, sex therapy costs $75 to $175 an hour. Some health insurers cover it. Others don’t. And some place limits on the number of covered sessions, after which you pay out-of-pocket. Check your policy.

Some people wonder if the sex therapist’s gender affects the quality of the therapy. “People have personal preferences, which is fine,” Sugrue says. “But the research shows that the therapist’s gender doesn’t matter. Men and woman respond equally well to male or female therapists. What matters most is the rapport between the clients and therapist.”

A HAPPY ENDING

Alan and Diane saw Weston for 44 sessions. During their conversations, Diane described her sexually repressed upbringing and what a struggle it had been--and continued to be--for her to open up to Alan both sexually and emotionally. This was a revelation to Alan, who apologized for having been so sexually demanding. Both Alan and Diane realized that her complaints about being the major breadwinner had less to do with the money than with her need to keep some emotional distance between them. Meanwhile, when she carped about money, he just became more sexually needy. Weston also gave them some educational materials about oral sex, showing that it was hygienic and safe for women to receive, which allayed Diane’s fears.

Thanks to sex therapy, Diane stopped putting Alan down for making less money, and he became less sexually demanding. They evolved toward a more affectionate relationship, with more of the cuddling that Alan wanted. Diane tried receiving oral sex and enjoyed it. She still felt less interested in sex than Alan did, but their desire discrepancy became less thorny an issue. They enjoyed each other more, and they enjoyed their sex more as well.

“Good sex is one of life’s greatest pleasures,” Sugrue says. “If you’re not enjoying it as much as you’d like, there’s no reason to feel inadequate, embarrassed, ashamed, or resentful of your partner. Sex therapy can usually help. The effort not only improves the quality of sex, but also deepens the trust and intimacy in the relationship.”


Box:
Self-Help for Sex Problems

Before you commit the time and money sex therapy requires, consider a self-help book. Self-help programs can help women learn to have orgasms and overcome vaginissmus, and can help men learn ejaculatory control, and resolve some erection problmes. The experts quoted in this article recommend:

For women:
* Becoming Orgasmic by Julia Heiman, Ph.D., and Joseph LoPiccolo, Ph.D.
* For Each Other by Lonnie Barbach, Ph.D.
* When a Woman’s Body Says No to Sex: Understanding and Treating Vaginissmus by Linda Valins (out of print, but available at many public libraries)

For men:
The New Male Sexuality by Bernie Zilbergeld, Ph.D.
Sexual Solutions by Michael Castleman


Box:
How to Find a Qualified Sex Therapist

* Ask your family doctor or gynecologist. Medical problems contribute to many sex problems, so it’s a good idea to begin with a check-up. If nothing turns up, ask the doctor for a referral to a sex therapist.

* If you feel comfortable doing this, ask friends.

* Call local or state psychological or social work organizations, and ask for referrals.

* Write to AASECT. (P.O. 238, Mount Vernon IA 52314-0238). If you include a stamped, self-addressed, business-size envelope, the organization will send a list of ASSECT-certified sex therapists in your area. Some--but not all--AASECT-certified therapists are also listed on the organization’s Web site: www.aasect.org.

* Once you have a short list of possible sex therapists, interview them briefly by phone. Ask about their experience dealing with your problem. Ask about their credentials, approach, when you might arrange sessions, and cost. Select the one with whom you feel the best rapport.