Physicians and Clinicians Guide: Sex Therapy

Informal paper: Information for Physicians and Clinicians: qualifications to provide Sex Therapy

            To heal and do no harm to patients who present with the prevalent sexual and relationship problems of the 21st century, comprehensive and specialized education and training are needed. Just as general and family physicians diagnose and treat an array of common physical ailments, general and family therapists diagnose and treat an array of common mental health and family problems. A good general physician refers patients appropriately to specialists; patients know that specialists have the training and experience to deal with specific problems. What is not well known is that sexual problems and treatments are currently a specialty. Research of the past two decades has brought knowledge of sexuality, the brain, and relationships, and, therefore, of treatment of sexual problems well beyond general medical and therapeutic training.

Because of patients’ needs, some physicians and therapists – ethically motivated and confident that their approaches are sound – do undertake treating sexual complaints. Unfortunately treatment approaches commonly being used are at best not fully effective and at worst, actually compound sexual, personal, and relationship problems. This is a case of well meaning and otherwise qualified professionals not realizing how much they don’t know. Concomitantly with brain science, the field of sex and relationship therapy has grown, especially in the recent decade, but education about the field has not.

 

Qualifying as a sex therapist

A certified sex therapist is a specialist. Few ways of becoming qualified exist; only a few colleges offer any focus on sex therapy. Perhaps the best-known organization to provide certification is AASECT (American Association of Sex Educators, Counselors, and Therapists). A sex therapist certified by AASECT must first be a licensed, master’s level psychotherapeutic clinician. Then coursework and hundreds of supervised hours working specifically with relationship and sexual issues must be completed. A practitioner without AASECT certification, or one of the few recognized degrees in clinical sexology, is not qualified to accurately and comprehensively deal with sexual issues.

Certified sex and relationship therapists are also required to complete yearly continuing education programs. The field of sex therapy has much scientific, specialized, and continuously expanding information and treatment tools, which are rarely followed by physicians, psychologists, or other psychotherapists – all of whom have their own requirements to keep up with!

As information concerning sexuality and treatment becomes more widespread, focused training opportunities grow. For example, sexual abuse is a focus for which a range of specific certificates and treatment approaches are available. It is important to note, however, that such targeted training opportunities may fall short of providing tools to help patients develop intimacy and a positive, functional sex life after dealing with a specific problem.

 

Aren’t marriage and family therapists trained to treat sexual issues?

It’s a reasonable expectation that practitioners with a license to treat marital problems can effectively address sexual issues, at least with couples! It’s surprising that requirements for licensure as an MFT (marriage and family therapist) do not include any sex therapy courses, nor are any offered in most programs that provide MFT clinical training. In a survey of practitioners by The American Psychological Association, most respondents stated that they did not feel qualified to handle sexual issues, and that sexual issues come up in approximately 70% of cases.

How can physicians and psychotherapists approach sexual problems?           

Several sexual complaints have a medical component, which may be helpful or imperative to address prior to or during clinical work, but it is important to be clear that few academic and training requirements for physicians, psychotherapists, or clinicians include any sex therapy. Asher’s 2010 meta-analysis of requirements for medical, doctoral, and clinical master’s degrees revealed that only 2% even address human sexuality – far from synonymous with sex therapy, for which no requirements exist. Unfortunately, physicians and general clinical practitioners do not have the training to effectively discuss sex and assess sexual situations, nor the tools to provide full treatment.

The best approach is one of collaboration between practitioners. As one example, women complaining of low sexual interest who consulted with both a gynecologist and a sex therapist reported a 25% improvement from medical help (treatments for hormonal balance, lubricants, and “designer” enhancement creams), and 75% of the reported overall improvement in their sex lives from utilizing tools, information, and support from sex and relationship therapy. Women rated intimacy and quality of sexual experiences at a median of 2 when they began treatment; the same women and their partners rated their sex life a median of 8 after utilizing both medical and sex therapy interventions, including at 6 month and 1 year follow-up.

The medical components of treatment were described as helping with physical comfort and function – certainly imperative in supporting clinical therapeutic work of developing a healthy, satisfying sex life. Similar types of cases involving erectile dysfunction, sexual pain, and other male and female health issues confirm the necessity for both medical and qualified sex therapy treatment.

In some cases, sexual issues may improve for an individual or couple with general psychotherapy. Trauma, mental health, communication, anger, and other problems can severely impact intimacy and sexuality. When such issues are dealt with, sometimes sexuality improves as well. More commonly, however, intimacy and sex have “taken a hit” amidst the other problems and remain completely ignored or inadequately addressed even when other problems have been resolved. Yet another scenario is that sexual problems that don’t get discussed were the cause of other presenting issues.

Sex therapists often hear such statements as, “We went to a marriage therapist but the sexual issues – we didn’t feel we could even bring that up.” Or “We went to therapy before; we’re doing better but the sex part is still a real problem.”  Non-certified clinicians do not know how much they don’t know; nor does the patient seeking treatment. The differences between general, marriage, and sex therapists are not well known, and no separate category for certified sex therapy exists in marketing venues. A qualified sex therapist can be hard to find.

Do sex therapists treat other issues?

By definition, sex therapists must be able to treat issues in addition to those presenting as sexual. Because sexuality is integrated with many body mind functions, AASECT certification requires that the specialist be a licensed psychotherapeutic clinician. Sex therapy incorporates general psychotherapy because sex is not a disconnected, isolated issue existing in a box. Sexual difficulties may also be symptoms of other even more fundamental emotional, spiritual, physical, or mental problems.

Well-delivered sex therapy is holistic, comprehensive personal and relationship therapy, which includes directly addressing sexuality and intimacy in the context of overall treatment. Many therapists who specialize in sex therapy focus their outreach and practice on individuals and partners whose presenting issues include sexuality as one primary complaint.

 

The sex therapist’s toolbox

Sex therapy is a wide field rich in information and approaches designed to integrate treatment of sexual symptoms with overall personal and relationship therapy. This usually means talking in detailed depth about sexual experiences, problems, history, and symptoms, then offering research-supported intimacy/sex education and activities (“homework”) appropriate to each issue and patient.

Some tools of sex therapists may be similar to those tried and true techniques used in general treatment, but modified or expanded to include direct attention to sexuality. These include providing scientific, social, and cultural information; CBT (cognitive behavioral therapy); teaching mindfulness practices; supporting and integrating spirituality; psychodynamic approaches; psychosexual education; applied brain science; working with physicians and complementary/alternative health practitioners; applied family and consumer sciences and more. In sexological circles, sex therapy itself is viewed as an approach.

One technique called sensate focus, originally developed by Masters and Johnson and widely used in sex therapy, has been updated and adapted over the decades. Sensate focus can be part of effective treatment for a variety of prevalent intimacy and sexual problems, including those involving low desire, erectile dysfunction, sexual pain, past abuse, mental health issues, physical disability, chronic illness, age related problems, and others. Because it’s part of historic overviews, many practitioners may have heard of sensate focus, but clinicians without specific sexological training in applying the technique should not use it.

 

Working together to treat the whole patient

Clearly both medical and clinical sexological treatment are necessary for sexually oriented problems. While sexual symptoms highlight need for clinical attention, some sexual problems may involve a primary medical diagnosis such as those related to illness or disability, sexual pain, erectile dysfunction, and others. These conditions remain catalysts for relationship and family issues, however, so medical treatment is but one fundamental component of comprehensive help. Among the following top ten influences for development of sexual problems are items that may involve medical care, but assessment and treatment of how these manifest in patients’ relationships and sex lives is plainly outside the scope of medical practice:

*Personal and family background

*Cultural influences and misinformation

*Attention problems

*Stress and overwhelm

*Health issues

*Lack of positive information and experience

*Anxiety

* Trauma and PTSD

*Depression

*Obsessive and compulsive behaviors

Since few patients know where to seek help for sexual distress, physicians may be the first receivers of such complaints. Fortunately medical treatment is available for several sexual problems, but specialized help with issues that developed prior to or during medical treatment may frequently be needed. In other words, even when sexual issues and problems have a treatable medical cause or component, patients suffer consequences in their personal and relational lives that are beyond the scope of medical treatment or general psychotherapy. Clinical sexologists have empirically supported information and tools to directly address intimacy, relationship health, and sexual activity (following physician’s guidelines for the patient) prior to, during, and after medical and psychiatric treatments and procedures.

Treatment compliance and efficacy

It’s well known that regular visits to physicians and counselors promote self-care, treatment compliance and efficacy. Patients referred to therapists by physicians report a high rate of satisfaction with that physician, and with having concomitant clinical support. Research in several fields shows that empathy, expanded care, and comprehensive follow-up provided by therapy result in earlier complete recovery, improved immune function, and lower rates of relapse. Patients appreciate collaboration between practitioners; collaboration supports consistency, follow-through, and complete utilization of both medical and clinical resources by patients.

Studies show that most couples have not even discussed their sexual issues with each other, let alone a physician or counselor. Men are 60% less likely than are women to talk to a physician about health problems, especially those involving sexuality, until the symptoms become severe. When patients finally ask for help, if medical care includes the physician’s referral to a clinical sexologist, patients may feel justified hope that the issue is not only a medical one with limited treatment options: there are additional types of trustworthy help; they are not alone with their struggles when they leave the physician’s office; patients are relieved to learn that it’s OK to talk about sexual problems.

Conversely, if medical help with sexual problems doesn’t work or isn’t enough, and no referral to a sex therapist is provided, several unfortunate results may occur. Patients may lose faith in medical help; lose hope for getting better at all; conclude that they are even worse (“wow, even Viagra didn’t help me I must be really bad…my marriage is over…”). Some patients unsuccessfully and even dangerously try to solve the problems on their own; others may stop seeking help anywhere – which is a shame, and can lead to possible serious risks to well being.

Some sexual symptoms indicate unaddressed abuse, trauma, or other health issues that are not easily diagnosed by a physician without additional input from a therapist. Untreated sexual and relationship problems frequently lead to damaging personal, marital, and family problems, and impact community health.

Physicians have limited time; health care provides limited coverage

In the current economic climate and world of managed health care, treatment provided by physicians is regulated as to diagnosis and time. Even if physicians were provided with the necessary training, time is not allowed to counsel adequately for sexual and concomitant relationship problems, nor is payment approved.

Although several diagnostic codes exist for sexual complaints, these codes (whether or not empirically sound) are recognized but not covered by most insurance plans. Reimbursement to patients for therapy with a clinical sexologist is sometimes possible when other covered diagnoses are involved in the sexual and relationship problems. Time, tools, and training that physicians and general psychotherapists do not have are required to assess if and how approved diagnoses impact the sexual complaints of the patient.

Common problems addressed by sex therapists

As many physicians also experience, possibly the most common complaint received by sex therapists is low desire and low-sex marriage. “Low desire” and resulting low and no-sex marriages often end in breakups that in turn impact children and families. Low desire and low-sex marriage have many causes and many complications. These complaints need to be addressed by a qualified sex and relationship therapist.

Prevalence of low and no-sex marriages attributed to low desire bears brief discussion here since low desire is often treated as a medical and/or psychiatric problem. There are medically treatable components of low sexual interest; however, lack of sexual desire and activity are symptomsnot a diagnosis. The “official” diagnosis of Hypoactive Sexual Desire Disorder (DSMIV, 302.71) is unsound. There is no empirically determined “amount” of sex to want or have. There is no high, no low – because there is no norm – a fact stated in the DSMIV itself (p. 539). Sexological research has clarified over one dozen causes for so-called low and high desire in both women and men, only a few of which are biologically related or treatable in part with medications: a fact which supports the necessity for assessment by a qualified sex therapist in every case of low or high desire.

            This guide is written in the spirit of collaboration between practitioners for the purpose of ethically and effectively serving patients in our communities. Deliberate intention and action is needed to overcome the separateness of professional domain and practice unintentionally created by the vastness and complexity of our health care system. When medical treatment is provided to patients with the following complaints, consider as you would with many other health issues a referral to the appropriate specialist, in this case a qualified sex therapist, for further assessment.

Scope of practice – issues in clinical sexology

* low and high desire

*low or no-sex marriages

*desire discrepancy in relationships

*erectile dysfunction/rapid ejaculation

*inhibited orgasm/anorgasmia

*sexual pain/vaginismus

*compulsive sexual behaviors including “sex addiction”

*extra-marital affairs

*pre-marital counseling

*PTSD

*relationship conflict

*past or present abuse

*childhood or adult trauma and abuse

*sexual orientation issues

*alternative sexual interests

*persons with disability and chronic illness

*alternative and open relationships

*any physical, mental health, or relationship problem impacting sexuality

*family members and family issues involving sexuality: marital happiness, sex education and health, family life management, family planning

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