When people ask me what is sex therapy, my answer often comes as a surprise– sex therapy is simply regular talk therapy, which also includes a frank discussion of sexual issues and/or difficulties.  In other words, the skills necessary to be a good sex therapist cannot be separated from the skills of more general psychotherapy. And there is a specific reason for this– more often than not, the sex is just the tip of the iceberg.

Let me explain. An individual may come in to my office, complaining of a sexual difficulty, let’s say inability to enjoy sex, for example, but as we start working together it becomes apparent that this individual’s entire body is numb because he has shut himself off from ever having to feel intense, painful emotions again. So, in this instance, a deeper emotional issue has now begun to affect the individual’s sexual functioning, but the core issue isn’t the sex, it’s these nagging underlying painful emotions. The sex is merely the fire under someone’s butt to get him or her into the office, but the sexual issue will not and cannot be resolved unless the individual is willing to take a committed look at the deeper underlying issues.

This is just an example, and yes, sometimes sexual difficulties can be resolved without any of this deeper work. Often, because we live in a culture that is so confused about sex, just providing accurate sex education to dispel toxic and inaccurate beliefs is enough to send someone in the right direction. Or some behavioral interventions are sufficient when we are working with more of a specific fear, or a phobia, of sexuality.  More often than not though I have found that sexual issues run much deeper than simple education or basic behavioral interventions can reach. It’s the emotional issues that form the bulk of the iceberg.

In previous articles, I have written extensively about how specific emotions may, on their own, or in combination with other powerful emotions, create distressing sexual symptoms. Here’s a brief and incomplete rundown (along with accompanying links) of some of these emotions, along with the associated symptomatology.

Anger– male sexual dysfunction (ED, delayed ejaculation, rapid ejaculation), female sexual dysfunction (vaginismus, dyspareunia). I have written extensively about anger, so I will keep it short here and instead refer here for those who want to read more about anger.

Guilt– because it is often experienced as anger directed at oneself, the symptoms often mirror the ones of anger above. I would argue that in most high-functioning, neurotic (not psychotic) patients, anger and guilt are always co-mingled. Always. More on guilt here.

Shame– symptoms due to shame also include the sexual dysfunctions listed above, particularly when focused on shame about one’s genitals, as well as sexual compulsivity. Sexual compulsivity is the biggest symptom here and significant research points to the fact that shame is a big (if not the biggest) contributor to compulsive behaviors. Shame is another emotion that is interconnected with anger. To understand why, it is important to understand the difference between guilt and shame. While guilt is a subjective feeling of negativity directed at oneself for what one did, shame is a negative feeling about who we are. Because we develop our self-concept from the way we are viewed and treated by others, shame is one of those feelings that is initially instilled in us from the outside. As a result, if someone shames us, we cannot help but feel anger (even if it is unconscious) towards the individual(s) who created it within us. As a result, like guilt, shame is also always co-mingled with anger, but for very different reasons. For further reading, please take a look at my previous article about shame.

Grief– this is an emotion that I commonly see in individuals who cannot, despite their intentions, enter into or maintain a romantic relationship.  Commonly, someone may have unresolved grief about a former relationship. It doesn’t have to be a former romantic relationship, it could be a relationship with a parent for example. This kind of grief functions in two distinct ways. First, the individual may find him or herself constantly dating someone who reminds them of the previous relationship, constantly replaying the same difficulties and outcomes as in the past. Even Freud wrote about this back in the day, and called it the repetition compulsion. By replaying the themes of a previous relationship, the individual can feel like the past situation is still ongoing and there’s something that can be done about it. In other words, it’s not yet over. It’s still alive, not dead, and so the individual never has to grieve a dead relationship. Second, unresolved grief may lead to an unhealthy sense of allegiance, in which the individual may feel like they will betray a previous relationship by beginning a new, healthy relationship. I will write more about grief in a future post, since it is such a tricky emotion that many people can get stuck in.

Of course there are other submerged feelings, such as fear, but I will stop here for now, as the point of this article was to merely point out that often sex therapy cannot be effective in isolation outside of a more general psychotherapy aimed at resolving underlying painful emotions. That’s because sex is often just one symptom of a larger set of problems. Sex problems are rarely limited to just sex, and usually elements of the sexual difficulties can be found in other areas of the person’s life. Because sex is just the tip of the iceberg, it is merely just one (urgent) symptom of a deeper, unresolved emotional difficulty.