The history of sex therapy and what sex therapists actually do came up in the latest episode of The Real Sex Education podcast when we spoke to comedian Sarah Keyworth. She recently discovered a relative had been a relationship therapist and speculated about what this could mean and how much sex therapy may have changed since she was practising.
There is, in fact, a difference between sex and relationship therapists, though some practitioners, like myself, are both. Depending on their training, relationship therapists may work with all relationships, not just couples, so they could work with families, friends or work colleagues too. They will also have had special training, normally of at least two years and often considerably more, so you should look for someone trained to at least diploma level — sometimes people with no more than a weekend taster claim course they’re couple qualified.
Relationship or couple therapists will normally talk about sex if it’s appropriate, and both sex and relationship therapists may have particular interests in issues like sexual identity, relationship or sexual trauma. Sex therapists, though, are often relationship therapists who have had additional training (often to masters level or beyond) so that they can work with specific sexual issues, such as sexual pain, orgasm difficulties, loss of desire and erectile problems. Though some sex therapists have a medical rather than counselling training, relationship skills are always helpful, as relationship dynamics inevitably affect the progress of a sexual problem even when it existed long before a couple met. Look for sex therapists who are members of The College of Sexual and Relationship Therapists (COSRT).
Masters & Johnson
Though sex therapy in one form or another has been around forever, much modern sex therapy arose from the work of William Masters, a doctor, and Virginia Johnson, his research assistant, who studied human sexual response in laboratory conditions and later developed ways of working with sexual problems. As Masters’ initial research began in the late 1950s, it’s unsurprising that his work was controversial. It’s not just his topic or that his methods – such as laboratory sex – would be highly unlikely to get a green light today, but that his results weren’t universally popular. For instance, the idea that clitoral stimulation rather than penile thrusting in the vagina caused women’s orgasm was revelatory, but seen as a bit of an affront to men. Similarly, Masters & Johnson discovered that, unlike men, women can have multiple orgasms in a single session and that many women fake orgasm during intercourse. However, any implication that intercourse was an extremely unreliable way to cause women’s orgasms, or that women might be sexually deceiving their partners by faking, would not have gone down well with the mainly male medical community. To this day, Washington University, where Masters & Johnson’s original research was carried out, seems ashamed of having facilitated it.
Even though they demonstrated that some sort of clitoral stimulation was necessary for orgasm, they allowed a belief that correctly positioned thrusting could readily achieve this, which is not always the case at all. Consequently, for many years, sex therapists attempted to ‘help’ women ‘achieve’ orgasms during intercourse. Though there is nothing dysfunctional about being unable to, the male psychoanalyst Sigmund Freud’s earlier baseless denunciation of clitoral orgasms as ‘immature’, meant that many people saw so-called vaginal orgasms as more desirable. Coupled with the romantic notion of simultaneous orgasm, realistic non-vaginal, non-existent, or non-simultaneous orgasm became popularly pathlogised. Though Masters & Johnson demonstrated women’s remarkable sexual capacities, far from liberating them to enjoy more relaxed sex, the sexual revolution which followed their research has led to an expectation that women should be multiorgasmic. Much pressure on women to please partners by climaxing has led to response pressure in them and anxiety in men who feel they should be causing their partners to have stupendous orgasms.
Psychosexual therapy
The ultimate creation of more pressure was obviously not what intended, and they should be credited with revolutionising our understanding of sex and of treating sexual problems. They are, nonetheless, often criticised for being too clinical, phallocentric and heteronormative. Consequently, modern practitioners are trained to take a considerably more holistic approach, with many courses offering psychosexual therapy (PST) training, which emphasises the circular relationship between physical problems and psychological consequences. An example would be someone who has an episode of difficulty getting or maintaining an erection while tired or tipsy, but is then so worried about this happening again that it does actually keep repeating.
Virginia Johnson developed treatment based on cognitive behaviour therapy (CBT) to manage common sexual problems, often working with both partners, who would be given a series of touching exercises as homework to help them to relearn their sexual response. They were also offered behavioural and cognitive experiments to help manage anxiety and unhelpful thinking. This reflects a traditional CBT model, offering sex information, homework exercises, feedback and new exercises inspired by the feedback. Though adequate, and often very successful, a great deal of modern psychosexual therapy goes further, often treating underlying physical and/or emotional causes of sexual problems, as well as factoring in other relationship issues, cultural and contextual influences. It’s hugely complex, but very worthwhile, as most relationships are considerably improved by the process, and many people feel their overall mental health is better as they learn to manage their anxiety and mood changes.
As Sarah suggested in the podcast, sex and relationship issues often arise as a result of poor communication or the way partners communicate. A major problem is that many partners look to one another for reassurance and validation, but aren’t really paying attention to the other person. Consequently, many demands are made and most conversations may simply consist of tit for tat blaming rather than solution seeking. For many people, being right in the moment feels far more important than improving their situation, and they often don’t think beyond proving their partner is wrong or inadequate. Similarly, many people make assumptions about what their partner is thinking or feeling which are very wide of the mark. Many of us don’t bother to check out these assumptions so they can continue for years, with both partners unnecessarily hurt.
Tolerating not-knowing
Many modern psychosexual therapists actively discourage couples from discussing their touching experiments, instead supporting them to manage the anxiety of not-knowing. Once this is mastered, both partners become much better at recognising and communicating their own needs and noticing their partner’s too. We discussed this a bit in the Jayde Adams episode.
For many couples, both sexual avoidance and relationship conflict develop from fear of getting something wrong or of rejection. This creates excessive defensiveness, so that both partners are often unnecessarily primed for trouble. Consequently, any change in their own behaviour influences what happens within the relationship. Really positive improvements can therefore be made by smallish changes, such as checking rather than assuming, listening more carefully or just softening the way you a partner is approached. And don’t leave it too long to seek help from a therapist. As with all problems, the sooner you try to deal with them, the quicker they’re fixed.
- There’s a TV series, Masters of Sex, starring Michael Sheen and Lizzie Caplan, about Masters & Johnson’s lives and work, based on a book by Thomas Maier.
Cate Campbell 