Over half of the people who come to me for an initial session are interested in changing their sex life. They’ve made the difficult leap to talk to a stranger about it.
I always start with some straightforward questions (about age, kids, hobbies, and so on). Then I ask what they’d like from therapy, and they tell me their sexual situation. I ask a few questions about it (“How long have you been distressed?” “Is it like this when you masturbate?” “Have you spoken to your doc about this?”, etc.).
And then I want to talk about other things: depending on the patient, guilt/shame/anger; body image; the nature of their current (or previous) relationship; and depression or anxiety, to name a few.
That’s because for most people, sex is about more than sex. In addition to pleasure and closeness, sex may be about validation or humiliation; power; feeling accepted; being naughty or dirty; the desire to feel graceful or young or feminine; the possibilities are almost endless.
Here are a few notes about patients who wanted to talk about sex—and who were impatient when I wanted to talk about non-sexual things.
First, here are two different guys who came in with similar problems—unreliable erection and low desire. But their life stories were quite different, and so the context of their sexual problems were different.
Presenting Problem: E.D., Low desire
“I’m not assertive in bed,” O’Brien told me at our first session. “And my wife is disappointed about this. If I had better erections, I’d feel more confident.”
In fact, O’Brien isn’t assertive about anything; he told me he could never be “a manly man” like his brother, who had been in the Marines and fathered two kids by two different women.
We talked about the meaning of masculinity—did it have to be toxic? And we talked about assertiveness as a continuum, not as a binary. We explored him working with his wife to jointly establish their expectations of each other, so he wasn’t always feeling inadequate.
And it became clear to him that feeling intimidated like he did undermined both his desire for sex and his ability to get easily erect.
Presenting Problem: E.D., Low desire
Rick was engaged to “the woman of my dreams”—for now. Apparently, they had broken up two or three times in the past year. Why? According to her, he was selfish and too attached to his parents. According to him, she was unappreciative and demanding.
“Although I understand her upset,” he sighed. “Who wants a guy who can’t get it up?” And then there was the pressure from his parents. “They just want to see me settled, and they think Aisha is a ‘nice girl,’ so I should just marry her already. But her kids don’t like me, and she wants to have a kid with me, and I don’t feel ready for all that responsibility. But everyone says that at my age (43), I should just grow up.”
Rick really did believe that these various pressures should have no impact on his sexual desire or his erections. That was the key belief that had to change before he could change his sexuality. We talked about the importance and meaning of emotions for several months before coming back to his sexual issues–and we then did so successfully.
Here are two guys who presented with a different complaint.
Presenting Problem: Affairs; Desire discrepancy
From the start, Lee told me he was very attracted to his wife, and would have been more than content to just have sex with her. But her desire level was lower than his, which he took personally. He felt he somehow wasn’t attractive enough to trigger her desire for him.
In contrast, when he slept with women he met at the gym or his running club, he felt sure he was attractive. He wanted to stop having affairs, but he was afraid that without them, he’d collapse emotionally.
“It must be exhausting to have to keep proving your adequacy,” I said, which brought him to tears. I asked, “Was it your mother or your father whom you couldn’t please, for whom you were never good enough?” It was both. His father would get upset with anything less than perfect grades (and perfect trumpet recitals and perfect approval from the neighbors); his mother would tell him that if only he got straight As, the house would be more peaceful—and that his dad would stop yelling at her.
I told him what he really needed was to believe he was good enough, and to move on from his years of disappointing his parents. He didn’t believe this could be done. But with hard work (his strong suit) and introspection (at which he was inexperienced), he did it. He stopped needing the continuing validation of affairs, and when he could forgive himself, he developed a deeper connection with his wife. This newfound softness in their relationship actually increased her desire for him, and their ability to connect sexually.
Presenting problem: Prostitutes; Desire discrepancy
Before COVID, Trey travelled a lot for work. He developed a roster of sex workers across the country whom he would see, making dull business trips in dull cities more exciting. He wanted me to help him “control” himself, and to help him persuade his wife to have more sex with him. Then his wife found out about the prostitutes, and he wanted me to help him with damage control.
He told me that paid sex wasn’t always that great, so I asked why he kept going back to it. “I like the way these women make me feel,” he said sheepishly. “I know they’re basically acting, but they’re good at it—they make me feel desired, which I really need.”
What about his wife’s desire for him, was that not enough? “Oh, with her I’m vanilla,” he said. “With prostitutes I’m a bad boy. I can only be a good boy for so long before I want to bust out.”
I encouraged Trey to talk with his wife about his desire to be a bad boy—and his sense that this was unacceptable to her. Together, they explored this unnecessary dichotomy in this thinking. There’s a part of him that instinctively resists authority—and sometimes he imagines unreasonable authority that isn’t there, which was the case in his marriage.
Exploring his unconscious belief that he had to rebel in order to maintain his adulthood was key to understanding his periodic choice to undermine the intimacy of his marriage. And that enabled him to invest more in his sex life with his wife, and to find alternate ways to make his business trips more enjoyable.
Because sexual problems are rarely about sex, resolving them generally involves insights and decisions about non-sexual things. Instead, many people (and therapists) try to make sex more intense–with Viagra, lingerie, handcuffs, or porn–which is usually the wrong approach. Instead, we need to investigate what non-sexual issues are getting in the way of satisfying sexual function and decision-making.
That’s why when people ask me how to define “sex therapist,” I say “That’s a good therapist who doesn’t get distracted by sex.”
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