Family Therapy Magazine at the American Association of Marriage and Family Therapists. (published in Oct 2021)
By Debbie Marielle Elzea, psychotherapist, CO, and Jennie Marie Battistin, LMFT
"How's Your Client's Sex Life?"
We live in a culture that is both sex-obsessed, and starving for genuine, loving connection.
According to the Journal of the American Medical Association (JAMA), an astounding 42% of American women have low libido or desire, pain, and/or elusive orgasms. Many more lack emotional connection with their lovers. This is a concern for Marriage and Family Therapists, (MFTs) as disappointing or non-existent sex lives are leading causes of breakups and family dissolution. Further, healthy, fulfilling sexual lives are essential for physical, mental and emotional well-being, and sex provides a unique opportunity for connection and bonding.
Couples face many sexual challenges, and it is natural for MFTs to view issues from a systemic or couples perspective. However, many sexual problems are individual challenges and have individual solutions. Blocks like body shame, negative conditioning, or the inability to relax and ‘get out of her head’ are very common for females regardless of background or relationship. To determine whether a challenge is a couples or individual issue, a rule of thumb is to consider whether the challenges predate the couple's relationship and/or would exist independently of the relationship. If so, the individual may be best served in a one-on-one setting.
This article will help MFTs understand the most common blocks and challenges from the female perspective. It will also distinguish at a high-level distinct approaches used by sex therapists versus sex educators and coaches, so you can feel comfortable making referrals when sexual issues take you take you out of your expertise or comfort zone. This paper will contrast the therapeutic methods used by sex therapists and the skills based, experiential, and self-growth approaches used by sex coaches or educators.
Sexual issues are often a root cause of dysfunction, yet shame and conditioning may prevent the couple from bringing the subject up themselves, even in therapy or couples counseling. Conversely, many therapists are reluctant to ask this question, as they have limited training in working with sexual problems and may even be embarrassed by having sex talks. Not addressing sexual challenges is a lost opportunity, because a loving physical bond can cause other grievances to lose importance as great sex floods the lovers with pleasure and bonding hormones.
While traditional sex therapy is often about healing past wounding, trauma, abuse and understanding emotions, coaching is skills and mindset based, and future oriented. If therapy has a goal of getting a client to a baseline of normal, sex coaching’s goal is to empower the client to create the pleasurable, connected sex life they desire.
Not every sexual dysfunction has its origin in trauma or the past. If a woman struggles, she is not broken; it may simply be that female sexuality is inherently complex, a science, an art, and a learned skill, that no one taught her. It may be that she has received negative messages about her body or desires, doesn’t have experience or education, or she doesn’t feel comfortable discussing sex. Sex and intimacy coaching fills a gap between therapy and self-growth, helping women shed shame, negative conditioning, learn about their bodies, arousal and response cycles, their unique likes, dislikes and turn-ons, and how to ask for what she wants from her lover.
Six Things Women Need (by Debbie Marielle)
Few women understand physiological facts about arousal: for instance, that the clitoris is similar in size to a penis, with 95% under the surface like an iceberg. That there are a half dozen types of orgasms to experience. That neglect or trauma may cause a body to feel desensitized or numb. That the brain is the most important sex organ, and that it can be rewired to experience more pleasure via practice, touch and imagination.
Coaching provides a personalized sex education so a woman learns not only the facts, but also discovers her own preferences, turn-ons, and arousal cycles as well as dislikes and boundaries. She learns how to communicate her desires and preferences to her partner in a way that feels connected and not critical.
Worthiness and Confidence
Growing up, many women received negative messages about their sexuality, bodies and desires, which can cause lasting shame, confusion and guilt. These might be considered micro-traumas as opposed to “capital T’ trauma sex therapists regularly see. A goal of both therapy and coaching is to release shame and shift mindsets in an atmosphere of empathy and support. Talking about and normalizing sex gives a woman ‘permission’ enjoy her sensual self and celebrate her desires and fantasies.
In addition, as a stressed out, unhappy woman is unlikely to experience much physical pleasure and joy, in coaching she is encouraged to keep her spirit and self-love tank full with self-care and gratitude practices. Worthiness means she does not need a perfect body, relationship or performance to enjoy pleasure, because confidence, skill, relaxation and enjoyment are what make her a satisfied and exciting lover.
A great sex life does not just happen; it needs priority and time. ‘Mutually spontaneous desire’ is a myth, and there is nothing wrong with planning sexy times. Coaching keeps her accountable for stress relief and self-care practices that boost her happiness and confidence, and lovemaking is given time and priority; not just relegated to the end of the day when partners are exhausted.
In addition to prioritizing lovemaking, the female body needs time for arousal. If a man’s sexual response is like a microwave, a woman is more like a wood stove that needs kindling and fuel to be stoked. Parts of female anatomy need 20-40 minutes of attention to be primed, yet the average sex act is over in 6 minutes! It is no wonder women have an orgasm deficit compared to men and faking is so prevalent. In coaching she discovers turn-ons, techniques, rituals and touch she likes--then apply them in an unrushed, sensuous way.
A top sexual complaint of women is the inability to get ‘out of their heads’ and into pleasure—it can be a challenge to banish distracting thoughts, judgment, performance anxiety and the furtive chase of orgasms. Many women feel numb or distracted, as their touch sensitivity has been diminished by a lack of pleasurable touch, menopause, or trauma. Fortunately, sensitivity and focus can be revived and enhanced through mindful sensation practices, which use elements of breath, movement, touch, sound, and imagination. Rewiring the body and brain to receive more pleasure is a process that takes effort and support. Guided visualization, breathwork, mindful touch and home play practices help her break out of distracting thought patterns and connect with heart, body and sensuality.
Coaching teaches embodied sensuality; however if her lack of ability to relax is due to unresolved trauma, a trained sex therapist can help resolved negative cognitions and freeze responses that will allow women to move back into their bodies and experience their sensual self.
Despite a vast sexual menu, most couples have the same type of sex, year after year, and bedroom boredom is a leading cause of relationship dissatisfaction. In coaching we explore what she wants sex to mean emotionally, as well as the scenarios that turn her on. A client has the opportunity to experiment with varied themes such as passion, romance, energy, submission and dominance, plus the many forms of stimulation and lovemaking beyond the standard penis-in-vagina intercourse….from which less than a third of women reliably orgasm.
Sex with deep emotional connection is often the ultimate goal. If a romantic relationship lacks emotional connection, a woman is unlikely to feel ‘in the mood’ or fulfilled. Sex and intimacy coaching includes relationship components that help dissolve resentments and fighting, including gratitude, reframing, expectation setting and giving.
She learns to communicate desires to her partner in a connecting and playful way, rather than the dreaded, ‘we need to talk.’ In coaching she learns how to ‘invite’ her partner’s attention, creating an atmosphere of loving appreciation and intimacy.
Where to Refer a Client
You can see now how sexual problems are not always couples problems, and how a woman may benefit from therapy, education, practices, skills, and/or confidence building independently of her partner. When considering whom to refer to, both can help with the most common challenges such as low and inhibited desire, arousal and orgasm problems, and painful sex. The A sex therapist helps a client understand how the past got them to where they are today, and an intimacy and sex coach helps a client move from the present to their future desired sexual self.
A sex therapist is a licensed clinician that has often completed extensive training after their Master’s or Ph.D./PsyD and may have been certified through AASECT. Typically, a sex therapist helps client explore her past, heal from trauma around sex and sexuality, understand how trauma or mental health affects their sex life, and identify negative cognitions that underlie sexual dysfunction when no medical or organic reason exists. A sex therapist understands the intersection of biological, psychological and social factors that impact a person’s sexual health. Sessions are talk-based and therapeutic.
An intimacy and sex coach may have extensive training in sex education, coaching, and methods such as sacred sexuality, but there is no formal regulating body. Coaching is about education and empowerment and may resemble life coaching for the sex life. Coaching stays in the present and helps the client work towards their future desired sexual self. Most coaches use embodied practices. It is a good practice for MFTs to get personally acquainted with a sex coach or two to build trust and get a feel for their approach and methods.
When considering whether to refer to an intimacy and sex coach, the most pertinent consideration is whether mental health or trauma is a core concern. If so, therapeutic intervention is appropriate. If trauma or mental health is not a consideration, and she’d benefit from empowerment, confidence, skills and creativity, coaching is an option. Coaching also has a place when a woman has already worked on healing trauma in therapy, but still doesn’t know what she likes, or how to create the playful, pleasurable, connected sex life she desires.
Conclusion : “How’s your sex life?”
Sexual dysfunction, frustration, and sexless relationships are rampant for women and their partners. Sex problems and a lack of intimate connection harm mental, physical and emotional health, and break up many families. Shame, guilt, low expectations, and ignorance of alternatives mean that most of these women (and their partners) suffer in silence from sexual difficulties their entire lives, never seeking professional help. As the professional, it is appropriate to ask about the quality of the couple’s sex life, to uncover sources of conflict, and opportunities for growth and bonding.
Even if sexuality is not your specialty, we hope that this article has helped you understand that sexual challenges are not always a couple’s issue and that transformation can take various forms. New sources of help are available in the form of not only professional sex therapy, but also intimacy education and coaching.
Thanks for reading this far! Please let me know if you have any questions by replying to this email.
Debbie Marielle Elzea
Colorado psychotherapist, Intimacy Counselor for Women Worldwide!
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