Sex can be an important part of personal well-being. But sex therapists say the work they do remains misunderstood.
In the summer of 2017, six years into her marriage, Kayti Christian booked her first sex therapy appointment.
Ms. Christian and her husband grew up in evangelical families, steeped in the belief that any sexual desires outside of marriage were sinful. When they got married, they expected sex to be intuitive — even transcendent. Instead, Ms. Christian said she and her husband felt numb during intercourse and ashamed after.
They prayed. They asked their pastor for guidance, but it did not help. Finally Ms. Christian, now 32, started searching for local certified sex therapists.
They went to five sessions; sometimes together, sometimes alone. The couple’s therapist recommended simple exercises, like facing each other, holding eye contact and stating their sexual desires out loud.
“It might sound silly, but talking about sex while not having sex was something that felt revolutionary to us,” said Ms. Christian, who is working on a memoir about evangelical purity culture.
Sex is complicated for just about everyone — influenced by an ever-changing web of psychological, physical, cultural and social factors. And many individuals and couples can benefit from therapy to better understand their sexuality. Sex therapists say their field has long been misunderstood — seen as a last resort for people in doomed relationships, or a fringe practice that involves embarrassing hands-on exercises. For people like Ms. Christian and her husband, it can take years of suffering before they finally turn to a sex therapist for help.
There is emerging evidence that we may be in the midst of a collective rough patch, sexually speaking. Over the past two years, several studies suggest, people were having less sex and worse sex, particularly in the early days of the pandemic. A 2020 Kinsey Institute survey found that 24 percent of married people in the United States were having less frequent sex than before the pandemic, and 17 percent of women reported a decrease in sexual satisfaction.
Yet addressing sexual problems — whether they emerged during the pandemic or not — is challenging. Medicine has been slow to embrace sex as an important part of personal health, and many doctors do not receive formal sexual health training in medical school, despite known links between sex and wellness.
The New York Times spoke to several sex therapists about some common misconceptions around sex therapy and why it sometimes takes their patients so long to find care.
They made it clear that many issues can get in the way of good sex: past trauma, shame, body image, gender identity concerns, as well as broader relationship problems that can hinder someone’s ability to connect sexually.
“I always remind people that sex therapists have heard it all,” said Dr. Elisabeth Gordon, a New York City-based psychiatrist and sex therapist.
What is sex therapy and who is it for?
“It is really important to understand what sex therapy is and what sex therapy is not,” Dr. Gordon said. “Sex therapy is not requiring you to have sex in front of your therapist. Sex therapy is talk therapy.”
Certified sex therapists are licensed mental health professionals — usually psychiatrists, psychologists or clinical social workers — who do additional coursework in sexual health, sexuality and sexual pleasure. The most well-known certifying body is the American Association of Sexuality Educators, Counselors, and Therapists, or AASECT, which currently has just over 1,000 certified sex therapists across the United States.
Sex therapists work with adults of any sexual orientation, and see people in relationships (with or without their partner or partners) as well as single people. Ian Kerner, a sex therapist based in New York City, said more often than not, people seek out sex therapy because they have a specific problem they are looking to fix. He regularly treats patients with low or mismatched sexual desire, erectile unpredictability and early ejaculation, sexual anxiety, problems with orgasm and people looking to get out of a sexual rut — whatever that means to them.
In recent years, he has also seen an uptick in patients who don’t have a problem per se, but are simply looking for a greater sense of sexual adventure in their lives, or are looking for guidance as they explore the possibility of an open relationship; others are in new relationships and simply want to establish a happy, satisfying sex life early on.
Rachel Wright, a licensed marriage and family therapist and host of The Wright Conversations, a podcast about sex, relationships and mental health, offers this rule of thumb: If there is something about your sex life that you’d like to change, a sex therapist can probably help.
Keep in mind, however, that sex therapists cannot treat underlying health conditions that can contribute to sexual concerns, like erectile dysfunction caused by heart disease or diabetes.
“Sex is complex,” Dr. Kerner said. “Sometimes there may be a physiological element, like someone might be dealing with low desire due to the sexual side effects of a medication.”
What does sex therapy entail?
Therapists typically start by asking their patients about their background and past sexual experiences, as well as their goals. Dr. Kerner said they should also usually offer a rough time frame of their treatment plan in a first session.
“You don’t have to start therapy and meet every week for two years or the rest of your life,” echoed Ms. Wright. “You could go to a sex therapist, have a consultation, they recommend a book, you read it and you’re fine. Or they recommend a book, you read it and say, ‘Great, now I have five questions.’”
Homework assignments between sessions are common, and can include activities like massaging your partner while focusing on sensations like temperature, texture and pressure. Eventually, patients might work up to genital touch or experimentation with different techniques or fantasies — all taken at patients’ own pace, Dr. Gordon said.
For Ms. Christian and her husband, sex therapy homework was, as she put it, pretty “P.G.” Their therapist recommended they read books about the connection between desire and intimacy. They’d hold hands or massage each other, describing the basics of how it felt. Was the touch hot or cold? Did they like the pressure? Often, it just felt awkward.
“Sometimes it felt very tedious and uncomfortable. To sit in a bedroom touching each other’s hands for 20 minutes with soft music playing — we were like, is this over yet? What are we doing?” recalled Ms. Christian with a laugh. “But I think we realized that there wasn’t going to be a quick fix. We learned that we had to be patient.”
Sex therapy should offer validation.
While sex therapists tackle a vast range of issues, they say much of their work boils down to offering validation. And some, like Ms. Wright — who has written about coming to terms with being bisexual and polyamorous — are very open about their own sexual identities, which may be reassuring to patients who have felt misunderstood in the past.
“A lot of people I work with find me on their second or third try with therapy. They’ve maybe started with someone who doesn’t really have comfort or knowledge in talking about the specific sexualities that I deal with, and they’ve felt judged,” said Elizabeth Harles, a North Carolina-based sex therapist who often works with L.G.B.T.Q. clients, many of whom are looking to explore topics like kink and non-monogamy. She identifies as queer and polyamorous. And like Ms. Wright, she shares that experience openly.
“It’s tough to spill your guts to a stranger,” Ms. Harles said. “But talking about sex? Wow. It’s incredibly difficult to start that up with a stranger. If you then have a negative experience, that is really hard.”
“I can’t tell you how many patients I’ve had who come to me and tell me that their provider or practitioner told them, ‘Oh, just go relax. Have a glass of wine. Take a hot bath. It’ll all be OK,’” Dr. Gordon said. A 2012 survey of OB-GYNs found that only 28 percent routinely ask about sexual activity, while just 13 percent ask about pleasure during sexual activity.
In an effort to correct this, the Centers for Disease Control and Prevention has issued guidance for health care providers around what it calls the “5 Ps” of discussing sexual history with patients (their partners, sexual practices, how they protect themselves from sexually transmitted infections, past-history of S.T.I.s and their pregnancy intentions).
Some doctors say that is not enough.
“It feels like we are stuck in the 1980s,” said Dr. Susan Khalil, director of the division of sexual health in Obstetrics, Gynecology, and Reproductive Science at the Icahn School of Medicine at Mount Sinai. She would like to see more research into medications that can address sexual desire and function, surgeries to address physical factors that can affect sexual pain or pleasure and greater collaboration between doctors, sex therapists and physical therapists. That is happening in pockets around the country, but not everywhere, Dr. Khalil said.
For many, sex therapy can be the first stop on the journey to healing, rather than a last resort.
By the time they sought out a sex therapist, Ms. Christian and her husband were not nervous or embarrassed. Simply hearing that they were not alone helped. Ms. Christian said her sex life does not meet the unrealistic expectations she had before she got married, but described it now as vulnerable — and great.
“The validation was huge for us,” Ms. Christian said. “Having a therapist sit there with us and say: ‘Your experience is normal. There is nothing wrong with you. You just need to communicate about this more and practice’ — that was such a relief.”
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