We may be surrounded by sex, love and romance in all its forms – in TV, films and advertisements. Yet, when it comes to discussing sex publicly or privately, many people are still embarrassed or afraid to do so. They may lack the knowledge, understanding and experience to openly and honestly communicate around the topic of sex, for fear of being judged or ridiculed – especially if they consider their concern a ‘taboo’ area.
In sex and relationship therapy, there aren’t any taboo areas. If you are considering having sex therapy, you may have issues ranging from the medical and physical to the emotional and psychological. A sex therapist offers a comfortable, safe and supportive environment for you to focus on explore sex and relationships of all kinds.
Erectile Dysfunction and Performance Anxiety
“I am unable to get or sustain an erection and this is causing me to suffer from performance anxiety. What can I do?”
Erectile dysfunction can result from a problem with male sexual arousal via the brain, emotions, hormones, nerves, muscles or blood vessels. Other factors include stress, anxiety and depression, as well as smoking, alcohol/drug use and sleeping habits. All of these can then often lead to performance anxiety.
I would first recommend that you visit your GP to rule out any medical and physical causes and symptoms so I could then work with you on the possible psychological aspects to the problem. I would undertake a sexual history questionnaire and ask if you’re able to get an erection while alone and through masturbation, which would allow me to ascertain if the problem was general or occurred only when in the company of another. I would also explore areas such as low self-esteem, embarrassment and desire and satisfaction with their sex lives and relationship – or any concerns about your ability to get your partner pregnant. Taking any oral medications e.g. Viagra or use of penile pumps or implants will support the physical problem. However, where erectile dysfunction is psychological, the exploration of sexual desire and stimulation also needs to happen to fully solve the issue. Erectile dysfunction can be temporary and is often resolved through therapy to get to the root cause, whether it is medical or psychological or both.
“Generally, I am happy with kissing and touching. However, when it comes to sex and penetration, I panic and feel under pressure and this makes sexual intercourse impossible. What is wrong with me?”
There is not always a reason for vaginismus. It can be linked to sexual abuse or trauma, painful intercourse or emotional factors. The vaginal muscles involuntary or persistently contract, which can often prevent sexual intercourse and can cause pain. It is not only through penetration but can occur when inserting a tampon or even touched near the vaginal area, as well as during the menopause when vaginal dryness may occur. The good news is that it doesn’t always interfere with sexual arousal as it is the act of penetration that causes the problem.
I would first recommend that you visit your GP to have a pelvic examination and confirm that no physical problems are causing the tightening of the vaginal muscles. I would take a sexual history questionnaire and discuss whether it was primary vaginismus – where vaginal penetration has never been achieved – or secondary vaginismus, where penetration was previously achieved but where gynaecological surgery or trauma has taken place.
I will seek to gain a full understanding of how your anatomy works and what happens during sexual arousal and intercourse. We can also look at how you can do certain exercises and relaxation techniques, working alone and then with a partner, perhaps using vaginal dilators and kegel exercises, use of lubrication and certain sexual positions. If you have had a traumatic experience which led up to vaginismus e.g. surgery, abuse or rape, then the work would focus around the effects of these events on intercourse and penetration.
Couples: Lack of sex or intimacy in relationship
“We don’t seem to make love or have sex like we used to. My partner drinks a lot and takes drugs and I’ve recently lost my job, which is causing financial problems. What can we do to restore our intimacy?”
Sex is often affected when other problems arise in the relationship, as couples often find it hard to communicate without getting angry or upset about them, or may decide to not communicate about them at all in the hope that they will go away or resolve themselves. Such issues may be around career, health, finance, addiction, housing, family, children, retirement, etc. Sex, more often than not, then takes a back seat and will lessen or cease happening and therefore it becomes another problem to add to the list and may be overlooked.
Working with a couple I would undertake a relationship and sexual history questionnaire, looking at your communication styles and how you deal with particular problems. I would use tools and techniques such as Facts, Feelings and Requests, The Ladder of Sexual Arousal, Sexual Health Inventory for Men, as well as questionnaires to ascertain your levels of interest, desire and satisfaction with their relationship and sex lives generally. I will set you tasks and exercises both in the sessions and ones you can try at home in order to rekindle the intimacy you once had. Starting from the present and working backwards to explore how your sex and intimacy has changed, we can explore what you would like to be different going forward.
Sexual Fantasies and Paraphilias (Sexual Fetishism)
“I would really like to explore the BDSM world to enhance our sex life. However, I am worried my partner will find this weird or strange or think that I’m no longer happy with our relationship. I keep having fantasies about various scenarios and I wonder if this is normal?”
What is a fantasy? What is a fetish? Are fantasies OK to have if you only think about them rather than enact them? What is fun and what is dangerous? What is normal and what is abnormal? All these are questions you may wish to have answered in a world of likes and dislikes and desires for experimentation beyond what people consider to be acceptable in and out of the bedroom. What might appear bizarre to one person may be perfectly entertaining to another. There are a lot of sexual taboos and myths which as a therapist I would wish to dispel – and ensure that clients are made fully aware of what is legal and illegal, as well as how to deal with the religious, cultural and moral perspectives of people which may not match their own. My main concern is the health and safety of all clients whilst encouraging the ability to embrace sex and pleasure without feeling embarrassment, shame or guilt.
I would work with you as a couple from the beginning of when you met and your dating and relationship history. I would encourage you to discuss your sex life in the past and the present and how you would like to change anything in the future and look at any desire and resistance to this as individuals and as a couple. I would look at your knowledge and understanding already of each other’s fantasies/fetishes and conduct specific discussions around the BDSM world as the presenting issue in this case. Above all I would want you to feel you can express yourselves openly and honestly to each other in the session and leave with the necessary tools and techniques to improve your communication around sex.
If any of these issues or others are a concern or problem for you, then I would be happy to work with you and provide the help, support, strategies, tools and resources to use both in session and for the time between sessions.
Amanda Watson, Sex Therapist (Mind and Body Works)