Sex therapy provides a forum where all of the contributions to sexual difficulties can be identified and addressed, with the woman alone and with her partner, if she has one. In most instances, therapy begins with a careful and systematic assessment of the factors contributing to the current difficulty, including a review of past and present medical issues and a discussion about the woman and her partner’s ethnic or cultural background, religious devoutness, sexual beliefs and expectations, and goals of therapy. Further, the therapist wants to learn as much as possible about the woman’s past enjoyment and satisfaction with sensual or sexual activities, typical sexual response, and comfort with sexual behaviors, including oral-genital sex, fantasy or use of erotic media.
The prognosis is better for a woman who can recall past pleasurable sexual feelings or experiences and past or present loving relationships than if a woman has never enjoyed sex and is solely seeking to comply with her partner’s demands for more sex. Sexual desire may be rekindled and/or sexual problems may be resolved psychotherapeutically if a woman has enjoyed sexual relations with a current partner and wants to recapture it.
Women with orgasm difficulties tend to experience more sexual guilt, are less sexually assertive, and have more negative attitudes towards sexual activity and masturbation than do orgasmic women. Fear of loss of control with orgasm and other fears or misconceptions can be identified and discussed in sex therapy. Directed masturbation training has been found to be the most effective psychologic treatment for lifelong and generalized orgasmic problems, along with education and permission to engage in self-stimulation. For women with acquired and situational orgasmic problems who tend to be less satisfied with their overall relationship, sex therapy may focus on couples’ treatment and resolution of on-going relationship dissatisfactions. Most psychologic treatment approaches for orgasmic difficulties include a combination of sex education, sexual skills training, couple’s therapy, masturbation, and non-demand touching exercises, as well as interventions to address body image concerns and negative sexual attitudes.
For women with sexual pain complaints, a medical evaluation is required to determine whether there are any biologic issues contributing to the problem. Vulvodynia or vulvar vestibulitis is a fairly common problem in women and is often best treated by a multidisciplinary team of specialists, including gynecologists, psychologists, sexual medicine physicians and physical therapists. In addition to any medications and physical therapy exercises, massage and non-demand sensual exercises can be helpful in reducing sexual discomfort, along with sex therapy to challenge the negative and worrisome thoughts that often accompany sexual pain problems.
Sex therapy is typically brief, often no more than 10-12 sessions, but focused. Various therapeutic options include cognitive-behavioral therapy, permission and education, and “homework” assignments such as at-home sensual exercises or self-exploration.