What Is Sex-Positive Couple Therapy?

This piece was co-authored by Lisa Martin, LCSW‐R, CASAC, assistant director of mental health at the Montefiore School Health Program. She has over 25 years of clinical experience. This post expresses the views of the authors and does reflect those of Montefiore Medical Center.

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When most people hear the word 'communication' as it relates to couples, they think about conversations to resolve issues around money, child care responsibilities, or whose turn it is to do the dishes. Couples may call a therapist when one or both feel unheard or misunderstood. The therapist typically focuses on how partners use language, both verbal and non-verbal. If there's a sexual problem, many couple therapists refer the case to a certified sex therapist, and this is often good practice.

But more and more, couple therapists are expanding their knowledge of sex therapy theory and techniques so that they can integrate that aspect of treatment directly into their couple work. In meetings with such a couple therapist, solutions to sexual problems can be co-created. On occasion, treatment can transform a prosaic sexual relationship into a great one.

Verbal communication is essential, but uncovering and releasing inhibitions—caused by shame, guilt, negative body image, low self-esteem, and lapses in self-compassion—can require additional tools. Experiential interventions such as sensate focus, visualization, and mindfulness meditation can help facilitate change that talk therapy alone may fail to resolve.

Many couples need encouragement and support to allow themselves to experience mutual pleasure. An emotional and spiritual connection is crucial, but so is sex. A sex-positive therapist makes it their business to assess and, when appropriate, develop clients' capacity for sharing erotic intimacy and sensual companionship. This focus on sexuality does not come at the expense of attention to other couple therapy issues—such as basic communication—but is complementary to that work.

A range of difficulties stems from myths in our culture that sap sexual confidence and have nothing to do with flaws in couple communication. For example, there is a prevalent belief, reinforced widely in the media, that good sex is exclusively relevant to the lives of the young and conventionally beautiful. Another commonly held claim: Partners in long-term relationships inevitably lose interest in one another sexually—myths like these foster negative expectations that profoundly influence partners' attitudes and behaviors. Therapeutic conversations that debunk these and other sex-negative myths can have a dramatically positive effect on partners' self-esteem expand their sense of relational potential.

Despite the importance of sexuality in couples' lives, many certified couple therapists go through their entire academic and clinical training, receiving little or no guidance in working directly with sexual issues. Esther Perel, author of Mating in Captivity and a leader in the sex therapy field, stated in a New York Times interview that in her entire training in psychotherapy, she received "just one hour of education about sex."

Mutual enjoyment and appreciation are cornerstones of a healthy relationship, both sexually and otherwise. According to Barry McCarthy, a certified sex therapist, when partners feel good about their erotic connection, it absorbs approximately 15 to 20% of their day-to-day attention. When sex is dysfunctional, especially when partners avoid it, the negative impact is hard to overestimate. It is usual for feelings of intimacy and trust to become supplanted by blame, rage, and disillusionment.

In our search for compassionate, evidence-based, and even-handed wisdom on the subject of human sexuality, there are a handful of readings that have inspired and enlightened us. Pre-eminent sex therapist and educator Suzanne Iasenza recently released Transforming Sexual Narratives: A Relational Approach to Sex Therapy. It's aimed primarily at clinicians, but its clarity and sparkle make it an excellent read for anyone interested in human sexuality. Other titles that have significantly added to our knowledge base—and are enjoyable to read—include Come As You Are, by Emily Nagoski; She Comes First, by Ian Kerner; Love Worth Making, by Stephen Snyder; The Erotic Mind by Jack Morin; and Mating in Captivity, by Esther Perel.