A recent discussion on one of my professional list servs highlighted a common misconception that many in the public have about sex therapists. Specifically, it seems there is the idea circulating that sex therapists are only trained in helping individuals with sexual problems. This online professional discussion seemed to resonate with many, as it dragged on for several days and involved numerous contributors.

Suffice it to say, it got me thinking about my own experiences answering prospective clients’ questions, and it is indeed true that I am often asked whether, in addiction to sexual difficulties, I can also help people with other issues such as depression and anxiety (note to self: add this to the FAQ section). I answer that, as a certified sex therapist, I am first and foremost a licensed psychotherapist, so my foundational training is in general psychotherapy. Before sex therapy, I worked in hospitals and outpatient mental health clinics, just like any other mental health professional. Indeed, there is no separate track for sex therapy; if you want to become a sex therapist, you have to become a psychotherapist first (and then add a ton more specialized training after that).

The most common question I get however is whether I can provide couple’s therapy as well, or if not, should the individual hire a couple’s therapist in addition. This answer is complex because sometimes I get referrals from couple’s therapists when there is a particular sexual difficulty that they feel is out of their comfort zone, but suffice it say, a sex therapist generally must absolutely be skilled at couple’s therapy as well. Why? The short simple answer is that often times, sexual problems cannot be separated from the larger context of the relationship. In other words, sexual problems are often manifestations of deeper relational problems. The opposite is also true in that sex problems will most definitely negatively affect the balance of the relationship.

Often, I can’t even get to the sexual issues until the relational aspects are settled. It’s not uncommon for me to spend the first 75% of our work on the relationship, and often the sexual issues resolve rapidly once the relational piece has been addressed. As an example, about six months ago I finished with a couple where the presenting problem was erectile dysfunction. When they came in, they hadn’t had sex in 3 yrs and the description provided by the wife was that her husband’s ED was destroying their marriage. In other words, the root issue was the ED, everything else was fine. To make a long story short, turns out that years and years of resentment (that mostly had nothing to do with sex) had created so much overt tension and hostility in the relationship that it was more like a war zone than a safe space of love and nurturing. At least a large part of the ED was rooted in these emotional and relational turmoils.

No way in heck any sex therapist is going to solve that guy’s ED if he or she isn’t able to tackle complex couple’s therapy issues. In the end, it took us 2 yrs to rehabilitate that marriage and resolve the guy’s ED– 1 yr and 9 months to get the relationship to the point that we could shift our focus more on the sex and 3 months to fix the ED. In all 21 months on couple’s therapy, 3 months sex therapy, that’s a ratio of 7:1. Is there any question that a sex therapist absolutely, positively must be adept at couple’s work?

Sometimes it is the case that couples who come in for sex therapy don’t need much couple’s therapy. Those are the cases where the couple is already getting along well, can manage conflict, and can create a climate of collaboration instead of competition. Sometimes the couple needs a little work on differentiation, see here, to learn how to get both of their sexual needs met in a mutually beneficial way. These aren’t most of the cases, however.

More often than not, the couple is continuously replaying unhelpful relational dynamics from the past, the most commonly recreating a zero sum game where the attitude is “I win, you lose.” In this climate, the relationship is no longer a safe space of acceptance and collaboration, but rather competition and score keeping. Sex, which at its full potential must be experienced in a spirit of acceptance and collaboration, instead become just another bargaining chip in an endless and hopeless war.

In these cases, a couple that comes in complaining of sex may know that there is something wrong with the relationship but don’t know why and it is the sex which is the most obvious and glaring scapegoat. Perhaps, due to childhood circumstances, they may not even realize what is wrong with the relationship; it feels all too familiar. What definitely is obvious though is that there is something really wrong with the sex, because after all sex used to feel better than this. It all depends on one’s baseline. Had great sex before, but now it’s lousy? Need to fix the sex. Had a great experience of relationships growing up and this relationship feels off? Need to fix the relationship. Had great sex but dysfunctional relationships, and now both the sex and relationship is lousy? Need to fix the sex.

In other words, we all need to have had the experience of what feels great to be able to recognize what doesn’t. For most who find themselves trapped in difficult relationships, they may often unfortunately find themselves replaying old, familiar dynamics–which is why it is so difficult for them to articulate what is wrong in the relationship. However, most have had pleasurable sex at some point in their life, so it becomes much easier to point the finger at the sex, blaming it for all of the turmoil in the relationship. All of this is to say, that sex is often just the tip of the iceberg of the relationship. And if the sex is going to be resolved, so does the relationship. Which makes it essential, absolutely essential that any sex therapist is also exceedingly skilled at couple’s therapy.