Grayscale photo of shadowed couple kissing at sunsetSexuality refers to a person’s habits and preferences in terms of sexual behavior and desire. There are as many individual expressions of sexuality as there are individual preferences for dress or music. Some people may experience confusion or distress regarding some aspects of their sexual behavior or desired sexual behavior and seek help from a licensed mental health professional.

Sex therapists, counselors who are trained to help people work through any sex-related issues, may be a good choice for individuals who have questions or concerns about their sexuality or sexual activity. With the help of a sex therapist, many individuals are able to enhance or restore their enjoyment of physical intimacy. 

Understanding Human Sexuality

The concept of sexuality is complex and personal and usually entails more than just sexual activity. An individual’s personal definition of sexuality may include their feelings of attraction toward others, how they choose to be intimate with others, feelings relating to body image, and personal values. Sexuality can be expressed and experienced in a variety of ways, through thoughts, fantasies, behaviors, roles, and relationships. Further, although an individual’s sexuality may be influenced by their gender, orientation, and identity, these are distinct concepts. An individual’s sex refers to the sex that was assigned at birth based on physical anatomy, while gender identity refers to one’s internal knowledge of being male, female, non-binary, or other gender. Sexuality is also different from sexual orientation, which refers only to the type of sexual attraction that a person experiences.

Sexuality can be considered a developmental process, as it typically changes and evolves over the course of one's lifespan. In early childhood, a child often explores their own body and learns about love and intimacy through their relationships with primary caregivers. Children may engage in sexual play during later childhood (between age 4 and 8), often by playing “doctor.” During the adolescent stage, an individual experiences puberty and may start experimenting with masturbation and other forms of sexual exploration, becoming sexually active in the teenage or young adult years. In young adulthood, an individual’s sexuality continues to develop, and it is common in many cultures for an individual to begin thinking about choosing a long-term partner. The desire for sex may decline during older adulthood, though many people do maintain the desire for sex and other intimate physical contact.  

How Does Culture Relate to Sexuality?

An individual’s sexuality is likely to be largely influenced by their culture. In fact, some researchers believe sexuality is determined more by one’s environment than by genetics, and what is considered “normal” varies greatly by culture, religion, and historical period. Societies have different norms (and in some cases, even different laws) about premarital sex, non-heterosexual relationships, masturbation, monogamy, and sexual desires and practices. Sex therapist Jill Denton explains, "Each of us possesses a unique model of sexuality, formed at least in part by incoming family messages, childhood abuse or neglect, culture, the media, and, of course, religious influences," and sometimes these messages can prevent or disrupt the development of healthy intimacy.

Socialization to the sexual norms of one's culture generally begins at a young age through messages received from parents, the media, sexual education classes, and religious teachings. The prevailing views on sexuality in any society are influenced by religion, philosophy, history, and various other factors. In the United States, for example, religion has had a great impact on sexuality, though in recent years media outlets have increasingly offered a number of varying viewpoints, influencing ideas and beliefs about what is sexually acceptable and what is taboo. 

While there is no single culture that views sexuality the “right” way, problems can emerge when an individual’s sexuality does not fit into the norms of their culture. For example, an individual who is attracted to others of the same gender may experience shame or guilt if they are part of a culture in which only heterosexual relationships are considered acceptable. In such a case, an individual may become internally conflicted over whether to conform to cultural norms or follow their own wishes and desires in spite of likely stigma or prejudice. This struggle may in turn lead to sexual concerns or difficulty that can often be addressed with the help of a compassionate and affirming therapist.

Issues Linked to Sexuality

Sexual intimacy can be one of the most satisfying and fulfilling experiences, but for some people, sexual activity is devoid of pleasure. Often, sexual issues are a result of negative feelings or traumatic experiences that prevent a person from being able to fully participate during sexual intimacy. Sex therapist Jill Denton explains, "Each of us possesses a unique model of sexuality, formed at least in part by incoming family messages, childhood abuse or neglect, culture, the media, and, of course, religious influences," and sometimes these messages can prevent or disrupt the development of healthy intimacy.

Sexual problems can also surface as a product of another mental health issue, such as depression or anxiety, or they may be derived from physical conditions, such as bowel or urinary problems, chemical imbalances resulting from certain medications, or, for women, changing hormonal levels resulting from menopause or childbirth.

Sexual problems are not uncommon. Estimates of prevalence for adults in the United States range between 30% and 45%, depending on gender and age. Some of the most common concerns reported by those seeking therapy include:

  • Anxiety about sex 
  • The feet of two people sticking out from coversImpotence
  • Lack of sexual desire
  • Anxiety or uncertainty about sexual orientation
  • Conflicting sexual desires between partners
  • Recovery from sexual abuse or sexual assault
  • Loneliness
  • Body image issues
  • Sexual impulses or compulsions that cause distress
  • Promiscuity

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) lists three diagnosable sexual disorders for females and four for males, though these gender-specific categorizations have been criticized. Recent research indicates sexual interest/arousal disorder is not exclusive to individuals designated female at birth, and the addition of a gender-neutral category has also been proposed.

The DSM lists a number of paraphilias—sexual preferences for atypical behaviors—as being potentially problematic when specific criteria are met. A paraphilia might qualify as a paraphilic disorder when recurring personal psychological distress is associated with the behavior or when the distress or injury of another non-consenting person or group results from the behavior. Paraphilias that are acted out between consenting adults are not indicative of mental disorders.

Paraphilias listed in the DSM-5 include:

Fantasies associated with these behaviors are not necessarily cause for concern, unless the person experiencing the fantasy finds them distressing. In fact, most of these behaviors can be explored in a healthy, safe way between willing partners; they are considered problematic only when someone is harmed psychologically or physically by the act.

Addressing Sexuality in Therapy

Sexual intimacy is, for many, a highly satisfying and fulfilling experiences. For some individuals, however, sexual activity is void of pleasure, and this state may be temporary or last throughout life. Some people simply have no desire for sex, and this causes them no distress. Others are negatively impacted by issues relating to sex, and sexual energy, or lack thereof, may have a profound effect on their mood, thoughts, and general state of being.

When a person feels their sexual concerns or questions might be deemed inappropriate by partners, family, and friends, they may experience anxiety, frustration, and even shame, feelings that may lead to further distress. When this is the case, therapy may be of benefit, and finding the right therapist can offer a person a safe place to talk about any difficulties, fantasies, fears, memories, or desires regarding sexuality.

Sex therapists, psychotherapists who are specifically trained to help individuals and couples identify the source of sexual distress, deal with sexual issues, and/or reduce or remove emotional barriers in order to enhance sexual experiences, have experience treating issues related to:

  • Desire and arousal
  • Performance
  • Satisfaction
  • Sexual trauma/abuse
  • Sex addiction
  • Pain that occurs during sex
  • Conflict or confusion over sexual orientation

A wide range of interventions might be used in sex therapy, such as the exploration of sexual fantasies, mindfulness practices to help people become more fully present during sexual activities, education about sex, exploration of negative beliefs that impede sexual satisfaction, and the identification of the range of forms of sexual expression. Whether physical symptoms manifests through the inability to achieve orgasm, maintain arousal, or have sex without pain, a sex therapist is often able to help a person identify the psychological source of the symptom. By treating the whole person, psychologically and physically, sex therapists are able to help many individuals achieve improved sexual experiences. 

Case Examples

  • Sexual anxiety resulting from childhood: Donald, 47, has lately been experiencing feelings of anxiety and depression and has found himself drinking more and more alcohol to soothe these feelings. Hoping to achieve improved well-being and address the root of the feelings, he decides to seek counseling. He tells the therapist that he has never had a serious girlfriend, though he desires one and has had a number of casual relationships that, as he puts it, "fizzled out" when they approached the point of intimacy. The therapist’s questions about his romantic desires seem to cause Donald some embarrassment, and when the therapist gently inquires further. Donald reveals tremendous feelings of shame about the sexual feelings he experiences. Over a few sessions with the therapist, Donald is able to address these feelings, which relate to his strict religious background and a disturbing childhood experience of witnessing another boy being molested by a teacher. Donald reported the incident, he tells the therapist, but was never given the opportunity to discuss or work through his feelings about what he'd witnessed. Finally able to do so, Donald eventually overcomes his shame and fear and slowly begins to accept his sexual desires as a normal and healthy part of life. His low mood and feelings of anxiety diminish, and he renews his social life and is able to date with confidence, excitement, and a positive outlook. 
  • Uncovering new sexual attractions: Marcia, 34, is beginning to realize she is attracted to women and wants to talk about these new feelings with a therapist who can help her understand them. She reports she is happily married to a man and has no desire to leave him or seek a divorce but is at various times guilty, excited, confused, anxious, and overwhelmed by the new type of attraction she is experiencing. Telling the therapist she has had a number of fantasies about a woman she works with, Marcia further explains she believes the attraction may be mutual and that she is not sure whether to tell her husband or try to ignore the impulses. Therapy helps Marcia examine her feelings, the possible choices before her, and the best ways of communicating with her husband, whom she decides to tell. In a later session, she reports to the counselor that she had a productive talk with her husband and that he is not judgmental and supports her acting on her attraction as long as honesty and communication remain forefront in their marriage. Though Marcia does not conclude how best to proceed with the woman in her office, or other potential partners, she tells the therapist she thinks her relationship with her husband has become stronger as a result of their conversation, and she expresses a sense of confidence and peace with the realization that her attraction is simply a part of her nature, as well as happiness that she is loved and accepted. 

References:

  1. Alexander, B. (2006, May 25). When society gets in the way of sexuality. NBC News. Retrieved from http://www.nbcnews.com/id/12970326/ns/health-sexual_health/t/when-society-gets-way-sexuality/#.WG8ZJFMrLIV
  2. Boundless. (2016). Human sexuality and culture. Boundless Psychology. Retrieved from https://www.boundless.com/psychology/textbooks/boundless-psychology-textbook/gender-and-sexuality-15/sexuality-415/human-sexuality-and-culture-299-12834
  3. Brotto, L. A. (2015). The DSM diagnostic criteria for hypoactive sexual desire disorder in men. Retrieved from http://www.dsm5.org/Research/Documents/Brotto%202010.pdf
  4. Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). (2013). Washington, D.C.: American Psychiatric Association.
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  6. LGBTQ+ definitions. (2017). Retrieved from http://www.transstudent.org/definitions
  7. Paraphilic disorders. (2013). Retrieved from http://www.dsm5.org/Documents/Paraphilic%20Disorders%20Fact%20Sheet.pdf
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