- Body Image issues include women who feel insecure about their body (perceptions about too fat, too thin, too short, too tall and so on) and men who worry about their penis size and other physical issues (see my article: Is a Negative Body Image Ruining Your Sex Life?)
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| Sexual Anxiety Related to Body Image |
- Sexual Dysfunction like erectile dysfunction or unpredictability, problems with having orgasms, low libido or painful sex
- Shame and Guilt about sex that can stem from cultural issues, religion, family history and other factors
- Relationship Problems including conflict, arguments and other relationship stressors
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| Sexual Anxiety Related to Relationship Problems |
- Sexual Trauma including a history of sexual history of sexual abuse that can get triggered during sex
- Infidelity in a relationship which creates anger, resentment, mistrust and sadness
- Stress and Worry from other areas in life that affect sexual libido
- Sexual Inexperience can create anxiety about sexual performance, which often makes people feel self conscious and ashamed during sex
Clinical Scenarios
Many of these scenarios are a combination of problems and, as always, these vignettes are composites of many cases to protect confidentiality:
Clinical Scenario: Body Image, Shame, Guilt and Erectile Dysfunction
John
John grew up in a conservative religious home where sex was never discussed. Although his family never talked to him about sex, when he was 12 years old, he discovered his father's mainstream pornography collection, including films with explicit sex scenes.
Since sex was never discussed in his home and he attended a religious school where there was no formal sex education, these pornographic films were John's only introduction to sex and his only form of so-called "sex education" (in reality, these films, like most mainstream porn, provided a lot of misinformation).
John saw images of men in these porn films with huge penises. As as a teenager, he already felt inadequate about the size of his penis and these films made it worse.
By the time he had his first sexual experience in college, he felt ashamed of his body, especially the size of his penis. In addition, the fact that he was having sex outside of marriage, which was taboo in his culture, created problems for him with maintaining an erection.
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| Sexual Anxiety Due to Shame, Guilt and Erectile Dysfunction |
His sexual anxiety became an ongoing problem: His shame and anxiety about sex and his penis size made it difficult to maintain an erection and his problems maintaining an erection created even more anxiety. He was caught in what he thought would be an endless negative cycle.
He eventually sought help in sex therapy where he learned that his problem with sexual anxiety was a common one. His sex therapist provided him with resources, including books on sex education, where he learned that the size of his erect penis was average (the average size of an erect penis is about 5.16 inches).
John also learned in sex therapy how to overcome problems with sexual anxiety to stop the negative cycle he was caught in, including mind-body oriented techniques to help him relax and enjoy sex.
Clinical Scenario: Sexual Anxiety Related to Sexual Trauma and Pressure to Have Sex
Ann and Bob
Ann was sexually molested by her maternal uncle, who fondled her breasts, from the time she was 12 until she was 15. When she was younger, she was too afraid to tell anyone about the sexual molestation.
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| Sexual Anxiety Due to Sexual Trauma |
But when she was15, she told her mother, who didn't believe Ann. Ann's mother couldn't believe that her older brother would sexually abuse Ann, and she told Ann to stop trying to get attention by making up these stories.
Even though he was aware that Ann's mother didn't believe Ann, her uncle became so scared that his secret was out that he stopped touching Ann.
Logically, Ann knew she had done nothing wrong but, on an emotional level, she felt she must have been partly responsible for her uncle's behavior, especially since the fondling felt pleasurable to her, which made the experience confusing.
By the time she began dating boys at age 16, Ann dreaded the possibility of being kissed or touched by a boy.
When she got engaged to Bob, she was relieved that he wanted to wait until they got married to have sex. But on their wedding night, she was highly anxious. This set up a pattern where Ann tried to avoid having sex whenever possible, but when she felt pressured by Bob, she gave in to him reluctantly.
She never enjoyed sex because of her sexual anxiety. Every time she had sex with Bob, it triggered memories of her uncle touching her inappropriately. She just thought of sex with Bob as something to get through and she was relieved whenever it was over.
Two years into the marriage, Bob was fed up with Ann's lack of enthusiasm for having sex. After they started sex therapy, Ann reluctantly revealed her history of sexual abuse, which made Bob never knew about. Knowing about the abuse made him much more compassionate.
Ann also learned that it was common and normal for young girls who are sexually abused to feel sexual pleasure during the abuse. She learned that, even though she didn't want her uncle to touch her, her body responded naturally and spontaneously.
In addition to what she knew logically, she eventually felt on an emotional level that she was in no way responsible for the sexual abuse or the sexual pleasure she experienced during the abuse.
Their sex therapist recommended that, in addition to the couple's sex therapy session, Ann work on her unresolved sexual trauma in individual trauma therapy.
Over time, as Ann worked though her trauma and she and Bob worked on their issues as a couple in sex therapy, Ann began to enjoy sex and their sex life together was much more fulfilling.
Clinical Scenario: Sexual Anxiety Due to Relationship Problems and Infidelity
Ted and Bill
Three months after they started dating, Ted and Bill moved in together in Bill's apartment.
Prior to moving in together, they were in love and they had a fun and exciting sex life together. But after they moved in together, they realized they had different views about monogamy.
Bill liked to flirt and occasionally have casual sex with other men, but Ted was completely opposed to nonmonogamy. This caused frequent arguments and put a damper on their sex life together.
After Ted found out that Bill was having a sexual affair with a man Bill met at a gay bar, Ted felt angry, sad, resentful and mistrustful of Bill. Bill felt remorse for causing Ted pain so he ended the affair. But he told Ted he didn't want to stop having sex with men occasionally.
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| Sexual Anxiety Due to Relationship Problems and Infidelity |
Since they were unable to resolve these issues on their own, they sought help as a couple in sex therapy. Eventually, Bill admitted that he would like to have occasional flings with other men too, but he was initially too ashamed to admit this even to himself.
Their sex therapist provided them with psychoeducation about different types of consensual nonmonogamous relationships. She also helped them to work out an agreement as to what types of nonmonogamous behavior was acceptable to each of them and, eventually, they worked out a mutually agreed upon written agreement.
They agreed to have a consensual nonmonogamous relationship where they were primary partners to each other and all other sexual encounters would be casual.
They agreed they could have sex with other men occasionally, but they would try to avoid forming emotional attachments with these other men because their relationship was their primary emotional attachment. This meant that they wouldn't have sex with anyone else more than a few times to avoid becoming emotionally attached to them.
As issues with jealousy came up, they learned in sex therapy that jealousy was common. They also learned in sex therapy how to deal with jealousy.
Over time, they would revise their consensual nonmonogamous agreement as they encountered new situations they had not thought of before.
They both agreed that this form of consensual nonmonogamy worked best for each of them as individuals and for their relationship. As a result, their sex life became passionate again.
Clinical Scenario: Sexual Anxiety Due to Sexual Inexperience, Shame and Guilt
Ari
Ari and his family moved to the United States when he was 16 years old. They came from a conservative culture in their country of origin where talking about sex before marriage was considered taboo.
Since Ari's parents had an arranged marriage in their country, they hoped Ari would allow them to arrange a marriage for him. But he was adamantly opposed to this, and he told them that he wanted to choose his own partner.
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| Sexual Anxiety Due to Sexual Inexperience |
When he entered high school in New York City, to his amazement, Ari discovered that most of his classmates had already begun dating and having sex.
This created a great deal of anxiety and shame for him because dating and premarital sex was considered taboo in his country. He feared classmates would discover he had never dated or had sex with a girl and they would ridicule him. So, he tried to avoid the topic whenever it came up.
After a while, Ari resorted to making up stories about sexual exploits to tell the boys in school but, inwardly, he feared he would be discovered.
By the time he went away to college, Ari continued to feel conflicted about dating and sex. He felt caught between the culture he grew up as a boy in and the American culture he was currently living in. Part of him wanted to go out with women and have sexual experiences, but another part of him felt ashamed and guilty for wanting these experiences.
His attempts at dating and sex in college caused him shame and anxiety. He felt awkward asking women out on dates and he fumbled sexually.
The one and only time he attempted to have sex with a woman ended up being frustrating and embarrassing for him and the woman. Due to his anxiety, he had premature ejaculation and he ended the sexual encounter abruptly.
By the time he was in his mid-20s, Ari felt increasingly worried about his ability to date and have sex, so he entered into sex therapy.
He was able to work through his anxiety and conflictual feelings in sex therapy. He also learned how to remain focused on his and his partner's sexual pleasure rather than worrying about his sexual performance (see my articles: What is Performative Sex? and What is Sexual Self Esteem?).
Clinical Scenario: Sexual Anxiety Due to Stress and Worry
Rita and Jack
Before they had children, Rita and Jack had a sexually fulfilled sex life. Sex was fun and passionate between them.
But by the time they had two children, stress and worry intruded on their sex life. They worried about their children's health and whether they were good parents. They were also often exhausted by the time they put their children to sleep so they were too tired to have sex.
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| Sexual Anxiety Due to Stress and Worry |
Even when they both had enough energy to have sex, Rita was too distracted to enjoy sex because she was worried that one or both children would interrupt them by coming into their bedroom at night because the children couldn't sleep.
On their fifth wedding anniversary, they left the children with Rita's parents and they went away to have a romantic weekend. But when they were alone in their hotel room that night, they felt like strangers to each other. They felt too awkward to have sex--even though they were in a romantic environment with no interruptions.
After that weekend, they began seeing a sex therapist who talked to them about their sex script and how they approached sex from the initial encounter until completion (see my article: Understanding Your Sex Script).
They also had fun homework assignments to try at home between sex therapy sessions. Then, they discussed how they experienced these assignments in the next sex therapy session.
After a while, they planned another romantic getaway and they put into practice what they learned in sex therapy.
When they were at home, they developed a better sleep routine for their children to minimize interruptions. They also put a lock on their bedroom door so they wouldn't need to worry about the children coming in while they were having sex.
Clinical Scenario: Sexual Anxiety Due to Depression and Other Types of Anxiety
Ida
Throughout her life, Ida had experienced several episodes of depression and generalized anxiety.
By the time Ida was in her 30s and in a long term relationship with Jane, her depressive and anxiety-related symptoms were getting in the way of her sexual pleasure.
She experienced some relief from her symptoms after she saw a psychiatrist and he prescribed medication, but she still didn't look forward to either solo sex or partnered sex with Jane.
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| Sexual Anxiety Due to Depression and Generalized Anxiety |
Her individual therapist, who was helping Ida with her depression and anxiety, recommended that Ida seek help in sex therapy to deal with her low libido. Her therapist explained that, like most psychotherapists, she wasn't trained in sex therapy, which is a specialty, so Ida needed to seek help with a specialist who was trained in sex therapy.
At first, Ida was reluctant to see a sex therapist because she didn't know anything about sex therapy. But her individual therapist told Ida that there would be no physical exams, no nudity or touching in sex therapy. She explained to Ida that sex therapy is a form of psychotherapy, also known as talk therapy, and she encouraged Ida to have a sex therapy consultation.
Ida was relieved that her sex therapist was easy to talk to and Ida was able to open up about her lack of pleasure during sex. As a first step, her sex therapist also encouraged Ida to talk to her psychiatrist and find out if her medication was contributing to her lack of sexual desire.
After her psychiatrist changed her medication that didn't have sexual side effects, Ida felt more open to having sex with Jane, but she still experienced anxiety during sex.
So her sex therapist helped Ida with mind-body oriented techniques to help her relax more during sex and stay focused on her own and Jane's sexual pleasure.
At first, Ida had problems masturbating because she felt awkward and embarrassed about touching herself. But, at her sex therapist's recommendation, she started slowly by getting in touch first with what felt sensually pleasurable to her using her five senses--sight, sound, touch, smell and tactile pleasure.
Ida discovered she liked taking bubble baths using herbs in the bath that helped her to relax. She learned to create a sensual experience for herself by having scented candles, listening to relaxing music, and smoothing on body lotion after the bath. Afterwards, she was relaxed and open to pleasuring herself.
Not only did these sensual experiences help Ida to relax, they also helped her to discover what she enjoyed sexually. Then, she was able to talk to Jane about these sexual discoveries (see my article: How to Talk to Your Partner About Sex).
Over time, sex became pleasurable and passionate for Ida and Jane (see my article: Savoring Pleasure).
Conclusion
One article can't encompass all the problems addressed in sex therapy. This article attempts to cover some of the most common problems discussed in sex therapy.
One of the most common problems, sexual anxiety, is common. But people who experience sexual anxiety aren't aware of how common it is because people rarely talk about it outside of therapy.
You deserve to have a fulfilling sex life, so if you're experiencing sexual anxiety or other sexual problems, seek help in sex therapy.
About Me
I am a licensed New York City psychotherapist, hypnotherapist, EMDR, AEDP, EFT, Somatic Experiencing and Sex Therapist.
I work with individual adults and couples.
To set up a consultation, call me at (917) 742-2624 during business hours or email me.
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