Sex therapy is a strategy for the improvement of sexual function and treatment of sexual dysfunction. This includes sexual dysfunctions such as premature ejaculation or delayed ejaculation, erectile dysfunction, lack of sexual interest or arousal, and painful sex ( vaginismus and dyspareunia), as well as dealing with problems imposed by atypical sexual interests ( paraphilias), gender dysphoria and being transgender, highly overactive

libido Libido (; colloquial: sex drive) is a person's overall sexual drive or desire for sexual activity. Libido is influenced by biological, psychological, and social factors. Biologically, the sex hormones and associated neurotransmitters that act u ...

or hypersexuality, a lack of sexual confidence, recovering from sexual abuse such as rape or sexual assault, and sexual issues related to aging, illness, or disability.Binik, Y. M., & Hall, K. S. K. (2014). ''Principles and practice of sex therapy (5th ed.).'' NY: Guildford,

Practice

Modern sex therapy often integrates psychotherapeutic techniques and medical ones,Bancroft, J. (2009). ''Human Sexuality and Its Problems (3rd ed.).'' Edinburgh: Elsevier. such as Viagra (

sildenafil Sildenafil, sold under the brand name Viagra, among others, is a medication used to treat erectile dysfunction and pulmonary arterial hypertension. It is unclear if it is effective for treating sexual dysfunction in women. It is taken by ...

) and Cialis (

tadalafil Tadalafil, sold under the brand name Cialis among others, is a medication used to treat erectile dysfunction (ED), benign prostatic hyperplasia (BPH), and pulmonary arterial hypertension. It is taken by mouth. Onset is typically within half a ...

) to increase erectile response and Paxil ( paroxetine) to treat premature ejaculation. Sex therapists assist those experiencing problems in overcoming them, in doing so possibly regaining an active sex life. The transformative approach to sex therapy aims to understand the psychological, biological,

pharmacological Pharmacology is a branch of medicine, biology and pharmaceutical sciences concerned with drug or medication action, where a drug may be defined as any artificial, natural, or endogenous (from within the body) molecule which exerts a biochemic ...

, relational, and contextual aspects of sexual problems. Sex therapy requires rigorous evaluation that includes a medical and psychological examination. The reason is that sexual dysfunction may have a somatic base or a psychogenic basis. A clear example is erectile dysfunction (sometimes still called "impotence"), whose causes may include circulatory problems and performance anxiety. Sex therapy is frequently short term, with duration depending on the causes for therapy. Sex therapy can be provided by licensed psychologists or physicians, who have undergone training and become certified. These trainings and certifications usually begin with a master's degree, and internship, and a license. This can take up to 2 years, and longer if a doctorates degree is desired. Sex therapy is distinct from sex surrogates. Whereas sex therapists discuss and instruct clients in sex-based exercises to be performed at home between sessions, sexual surrogates participate in the exercises with their clients as part of helping them to practice and develop improved skills. Therapists and surrogates sometimes collaborate on cases. Certified sex therapists do not have sexual contact with their clients.

Symptoms

Sex therapy sessions are focused on the individual's symptoms rather than on underlying

psychodynamic Psychodynamics, also known as psychodynamic psychology, in its broadest sense, is an approach to psychology that emphasizes systematic study of the psychological forces underlying human behavior, feelings, and emotions and how they might relate t ...

conflicts. The sexual dysfunctions which may be addressed by sex therapy include non-consummation, premature ejaculation, erectile dysfunction, low libido, unwanted sexual fetishes, sexual addiction, painful sex, or a lack of sexual confidence, assisting people who are recovering from sexual assault, problems commonly caused by stress, tiredness, and other environmental and relationship factors. Sex therapy can either be on an individual basis or with the sex partner. Sex therapy can be conducted with any adult client, including older adults, any

gender expression Gender expression, or gender presentation, is a person's behavior, mannerisms, interests, and appearance that are associated with gender, specifically with the categories of femininity or masculinity. This also includes gender roles. These cate ...

, and

LGBTQ ' is an initialism that stands for lesbian, gay, bisexual, and transgender. In use since the 1990s, the initialism, as well as some of its common variants, functions as an umbrella term for sexuality and gender identity. The LGBT term is a ...

-identified people. A therapist's misunderstanding of these conflicts can lead to resistance or serve as a barrier to improving sexual dysfunctions that are directly or indirectly related to sex. The interest in sex therapy among couples has increased along with the number of sexuality educators, counselors, and therapists. Today, sexual problems are no longer regarded as symptoms of hidden deviant, pathological, or psychological defects in maturity or development. Sex therapy has also influenced the emergence of sexual medicine and exploring integrative approaches to sex therapy, in addition to reducing or eliminating sexual problems and increasing sexual satisfaction for individuals of all stages of life. Health therapists, educators, and counselors are conducting research and administering surveys to fully understand normative sexual function – what most people do and experience as they grow older and live longer.

Aging and sexuality

Both physical and emotional transformation throughout various stages of life can affect the body and sexuality. The subsequent decline in hormone levels and changes in

neurological Neurology (from el, νεῦρον (neûron), "string, nerve" and the suffix -logia, "study of") is the branch of medicine dealing with the diagnosis and treatment of all categories of conditions and disease involving the brain, the spinal c ...

and circulatory functioning may lead to sexual problems such as erectile dysfunction or vaginal pain. These physical changes often affect the intensity of youthful sex and may give way to more subdued responses during middle and later life. Issues with low

and sexual dysfunction are usually considered to be a byproduct of old age. The emotional byproducts of maturity, however — increased confidence, better communication skills, and lessened inhibitions — can help create a richer, more nuanced, and ultimately satisfying sexual experience. During

AARP AARP (formerly called the American Association of Retired Persons) is an interest group in the United States focusing on issues affecting those over the age of fifty. The organization said it had more than 38 million members in 2018. The magazin ...

's last surveys in 1999, 2004, and 2009 statistics show well-being among older adults has increased; however, overall sexual satisfaction has decreased. Nevertheless, older adults believed that an active sexual life offers great pleasure and contributes materially to overall emotional and physical health.

Older adults

Over the years, little attention has been paid to older adults and sexuality. As the population of older adults and life expectancy continue to grow, there is information about sex therapy but it is often not easily accepted. Cultural and sexual roles are always changing throughout the life-course. As people age, they are often viewed as asexual or as incapable of possessing sexual desires. The presence of sexual dysfunction during old age can be impacted by health problems. There are many

endocrine The endocrine system is a messenger system comprising feedback loops of the hormones released by internal glands of an organism directly into the circulatory system, regulating distant target organs. In vertebrates, the hypothalamus is the neur ...

, vascular and neurological disorders that may interfere in sexual function, along with some medications and surgeries. Older men experience changes that occur in sexual physiology and affect both erectile function and

ejaculation Ejaculation is the discharge of semen (the ''ejaculate''; normally containing sperm) from the male reproductory tract as a result of an orgasm. It is the final stage and natural objective of male sexual stimulation, and an essential component ...

. While older women experience

physiological Physiology (; ) is the scientific study of functions and mechanisms in a living system. As a sub-discipline of biology, physiology focuses on how organisms, organ systems, individual organs, cells, and biomolecules carry out the chemical ...

effects of aging after

menopause Menopause, also known as the climacteric, is the time in women's lives when menstrual periods stop permanently, and they are no longer able to bear children. Menopause usually occurs between the age of 47 and 54. Medical professionals often ...

, resulting in the decreased production of estrogen. This leads to increased

vaginal dryness Vaginal lubrication is a naturally produced fluid that lubricates a vagina. Vaginal lubrication is always present, but production increases significantly near ovulation and during sexual arousal in anticipation of sexual intercourse. Vaginal dr ...

, general atrophy of vaginal tissue, and genital changes (reduced size of

clitoral The clitoris ( or ) is a female sex organ present in mammals, ostriches and a limited number of other animals. In humans, the visible portion – the glans – is at the front junction of the labia minora (inner lips), above the open ...

, vulvar, and labial tissue).

Cognitive Cognition refers to "the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses". It encompasses all aspects of intellectual functions and processes such as: perception, attention, though ...

changes and decline is another factor that influences sexual activity. Dementia,

Alzheimer's Alzheimer's disease (AD) is a neurodegenerative disease that usually starts slowly and progressively worsens. It is the cause of 60–70% of cases of dementia. The most common early symptom is difficulty in remembering recent events. As t ...

and

mental health disorders The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the ''Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiatric ...

may have an effect on sexual behavior, producing disinhibition or relationship difficulties with subsequent effects on couple's sexual relationships. Sex therapy with older adults looks at factors which influence sexuality in older adults, including sexual desire, sexual activity, the value of sexuality, and health. It can include sensate focus, communication, and fantasy exercises as well as

psychodynamic therapy Psychodynamics, also known as psychodynamic psychology, in its broadest sense, is an approach to psychology that emphasizes systematic study of the psychological forces underlying human behavior, feelings, and emotions and how they might relate t ...

. Sex therapy for older adults is similar to sex therapy with other populations. It includes the use of water-based

personal lubricants Personal lubricants (colloquially termed lube) are specialized lubricants used during sexual acts, such as intercourse and masturbation, to reduce friction to or between the penis and vagina, anus or other body parts or applied to sex toys to red ...

(for decreased vaginal lubrication),

hormone therapy Hormone therapy or hormonal therapy is the use of hormones in medical treatment. Treatment with hormone antagonists may also be referred to as hormonal therapy or antihormone therapy. The most general classes of hormone therapy are oncologic h ...

, and medications.. Sex therapists working with older adults should know about sexuality and aging. They should also be aware of how stereotypes affect their clients. This is especially true for LGBT-identified clients. Older adults may also need more education about their sexuality and sexual functioning. Curriculum for this includes communication, masturbation,

body image Body image is a person's thoughts, feelings and perception of the aesthetics or sexual attractiveness of their own body. The concept of body image is used in a number of disciplines, including neuroscience, psychology, medicine, psychiatry, ps ...

, and

spirituality The meaning of ''spirituality'' has developed and expanded over time, and various meanings can be found alongside each other. Traditionally, spirituality referred to a religious process of re-formation which "aims to recover the original shape o ...

. It also teaches about talking to a doctor about sexual activity. It is optimal that sex education for older adults includes information about sexually transmitted infections (STDs/STIs), such as HIV/AIDS.

History

Sex therapy has existed in different cultures throughout time, including ancient India, China, Greece, and Rome. It has taken the form of manuals, spells, anaphrodisiacsLawless, Julia. The Encyclopedia of essential oils: the complete guide to the use of aromatic oils in aromatherapy, herbalism, health, and well being. Conari Press, 2013 or

aphrodisiac An aphrodisiac is a substance that increases sexual desire, sexual attraction, sexual pleasure, or sexual behavior. Substances range from a variety of plants, spices, foods, and synthetic chemicals. Natural aphrodisiacs like cannabis or cocain ...

s, and tantric yoga, among others. Much of sex therapy and sexual dysfunction in Western cultures was limited to scientific discussion, especially throughout the 19th century and into the early 20th century. Sexologists such as Henry Havelock Ellis and

Alfred Kinsey Alfred Charles Kinsey (; June 23, 1894 – August 25, 1956) was an American sexologist, biologist, and professor of entomology and zoology who, in 1947, founded the Institute for Sex Research at Indiana University, now known as the Kinsey Instit ...

began conducting research in the area of human sexuality during the first half of the 20th century. This work was groundbreaking and controversial in the scientific arena. In the 1950s, sex therapy was concerned with "controlling sexual expression" and repressing what was then-considered deviant behaviors, such as homosexuality or having sex too often.

Masters and Johnson The Masters and Johnson research team, composed of William H. Masters and Virginia E. Johnson, pioneered research into the nature of human sexual response and the diagnosis and treatment of sexual disorders and dysfunctions from 1957 until the ...

are credited with revolutionizing sex therapy in the mid-century and included couple therapy and behavioral interventions that focused on being present in the moment such as sensate focus exercises. Dr.

Helen Singer Kaplan Helen Singer Kaplan (February 6, 1929 – August 17, 1995) was an Austrian-American sex therapist and the founder of the first clinic in the United States for sexual disorders established at a medical school. ''The New York Times'' described Kapl ...

modified some of Masters and Johnson's ideas to better suit her outpatient practice, including introducing medication. Both integrated

cognitive behavioral therapy Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. CBT focuses on challenging and changing cognitive distortions (su ...

into their practice and Kaplan used

as well. The work of Jack Annon in 1976 also saw the creation of the PLISSIT model that sought to create a structured system of levels for the therapist to follow. The mid-1980s saw the

medicalization Medicalization is the process by which human conditions and problems come to be defined and treated as medical conditions, and thus become the subject of medical study, diagnosis, prevention, or treatment. Medicalization can be driven by new ev ...

of sex therapy, with a primary focus on male sexual dysfunction. The 1990s brought penile injections and medications such as Viagra as well as the marketing of

antidepressants Antidepressants are a class of medication used to treat major depressive disorder, anxiety disorders, chronic pain conditions, and to help manage addictions. Common side-effects of antidepressants include dry mouth, weight gain, dizziness, heada ...

for their delayed ejaculation side-effects.

Hormone therapy Hormone therapy or hormonal therapy is the use of hormones in medical treatment. Treatment with hormone antagonists may also be referred to as hormonal therapy or antihormone therapy. The most general classes of hormone therapy are oncologic h ...

was introduced to assist both male and female sexual dysfunction. Dilators were used to treat women with vaginismus and surgical procedures to increase the size of the vaginal opening and treat vulvar pain were also introduced.

References