Working With Sexual Aversion

I’m continuing my series responding to the answers my readers sent me in response to the question, “What is your biggest challenge working with sex issues in therapy?” This week, I’m discussing a really challenging one: sexual aversion.

Understanding a little about the Dual Control Model of sexual arousal will help you begin to approach sexual aversion with more confidence. The Dual Control Model was developed by Jansson and Bancroft from the Kinsey Institute. Emily Nagoski’s excellent book Come as You Are presents the model accessibly and in depth, if you want more information. 

The Dual Control is useful in understanding lots of sexual dynamics. The idea of the Dual Control Model is that sexual arousal isn’t an on-off switch. It has two components–excitation and inhibition, which Nagoski frames as being like an accelerator and a brake. That is to say, things that turn you on hit the accelerator, and things that turn you off hit the brake. The point is, you can stomp on the accelerator all you want, but if something’s holding down the brake, you’re not going to get anywhere.

With sexual aversion cases, generally what’s going on is that something is holding down the brake, hard. No matter what your client or their partner might do to increase stimulation (or hit the accelerator), nothing is going to improve in any substantial way unless they figure out how to let up the brake. Your job as a therapist is to help them identify what’s hitting the brake, and how to let it up.

Anxiety is the biggest brake ever. Sexual aversion is a form of anxiety, or even panic. Aversion sometimes results from a history of trauma, or from untreated sex pain, or a subtle (or overt) feeling of coercion or pressure around sex, but there isn’t always an obvious cause. If you think of it as anxiety, you’re more likely to get to the bottom of it. There might be subtle but pervasive shame about sex, for instance, or body image issues. Start with the Will Lily brief assessment to make sure you are targeting your questions and not missing anything crucial. (Spoiler alert: don’t forget to ask if any kind of sexual contact is uncomfortable or painful!)

Regardless of cause, there are some skills that usually require strengthening in order to resolve an aversion. These include: 

  1. Help them get control over the situation. Your client must feel in control, at all times, when in sexual contexts. It is extremely helpful if their partner is on board with taking a supportive role until the aversion resolves. The role of the partner is so important to this treatment plan, because aversion is an entirely systemic phenomenon. Any little hint of external or internal psychic pressure about sex will have to be addressed. If this is an individual client, see if you can have the partner come in every now and then so you can see the dynamics between them, and strengthen the collaboration and teamwork. It is also very helpful to have both partners in the room for complicated psychoeducation that requires a perspective shift, as is often true when discussing sex pain, psychic pressure about sex, sexual pleasure (which can really increase desire!), and sexual differentiation of self. The partner of someone with a sexual aversion probably also could really benefit from some support; it is an extremely difficult situation to be in! It would be fabulous if you could support them both as they learn to work together and heal this dynamic around sex. They have a lot to gain.
  2. Build their ability to identify desires, set boundaries, and hold those boundaries. Without the ability to identify desires, preferences, and boundaries, communicate them, and back them up with action, it will not be possible for the client to really feel in control.
  3. Diagnose physical problems. Painful sex will make aversion worse, guaranteed. Absolutely get any sex pain diagnosed and treated. While that is under way, the client will need to completely abstain from any painful type of contact.
  4. Practice relaxation or mindfulness. Once safety and control are in place, the linchpin of your treatment plan will be teaching the client, and their partner, how to relax in sexual situations and enjoy sex for the purpose of pleasure, rather than performance. This is a lot easier to do in a relational therapy where you have both partners in the room. Consider bringing in the partner for a few sessions if this is an individual client.
  5. Explore intrapsychic blocks. Ambivalence about sex is worth a deep dive. Look for signs of past or current trauma, including psychically “benign” sex pain, but don’t forget to look for subtle shameful messages about sex, which are extremely pervasive. What were they taught about sex? About themselves sexually? About people who enjoy sex? Are they able to enjoy pleasure in any aspect of their life? How about sexual pleasure? You can identify blocks by having a client talk you through a sexual interaction, step by step. Ask what occurred, but also what they were feeling, and what they were thinking. At the first little sign of anxiety, which might be merely a body sensation, delve into the multiple messages they are telling themselves in that moment. “What are you telling yourself to make yourself feel anxious?” “What are you telling yourself to make yourself feel scared?” Chair work can be very helpful in both uncovering and treating blocks of all types.
  6. Keep your client’s goals front and center. Don’t forget: Having sex is not a requirement of life. It is possible your client is asexual, or just not very interested in sex. Before you really dig into treating an aversion, ask where your client would like to get. There is no point in working toward a goal that your client isn’t interested in meeting. That said, if they have the type of aversion that comes with a big “ick” reaction or panicky feelings, they might want to resolve the negative feelings. But having anxiety-free sex is not the only possible positive outcome. Being in control of what they choose to do, even if that means being able to feel good about themselves while saying “no” to sex forevermore, would also be a great outcome.
  7. Refer or consult if necessary. If you don’t find your treatment plan progressing, a sex therapist can probably help. You might choose to refer the client, for a time, or permanently. You could also consult with a specialist every now and then as the treatment evolves, while continuing to do the therapy yourself.

Why Helping Your Clients Find the Joy is a Crucial Part of Couples Therapy

It is tempting to spend a lot of time in therapy working on making the things that are going wrong in relationships go better. But what exactly is that effort supporting, if the partners don’t connect, are constantly at odds, and becoming fatigued by all the conflict?

In my opinion, at least half of therapy must be about creating, improving and multiplying positive interactions. If your clients don’t feel like their relationship is worth the effort, of they don’t get joy out of each other’s company, hopelessness will win in the end.

Therapy is hard, because working as a team in an intimate relationship involves becoming more curious and less reactive. Nobody is going to work hard to modify their automatic responses in a marriage where fun has become extinct.

There are a number of ways you can help your clients rediscover the joy in their relationships. Here are some strategies to consider:

  • Help your clients remember positive interactions. Consider: What made them positive? How can the mood of those past interactions be re-created in current circumstances?
  • Create a positive interaction in your therapy room. I start most sessions by asking each partner to express appreciation or gratitude to their partner for something fairly specific they did or said recently that made a difference, and why. (A tip of my hat to the Developmental Model, once again!)
  • Remind your clients that positive aspects of their relationship continue to exist even when they’re not agreeing about something. Help them pay attention to those aspects of the relationship that are really working, and develop a practice of noticing and appreciating those moments.
  • Help clients create a daily positive interaction habit. Many clients already have at least one positive interaction each day, in which case it can be expanded to more, longer, or more meaningful. However, some clients many need to start small. Small or large,  being able to deliberately create a positive interaction is an indispensable skill for a strong relationship. It requires self-control, compartmentalization, making a clear choice, emotional regulation, motivation…all the skills couples need in order to function as a team.

As clients become better able to deliberately choose, create, and change the tone or atmosphere of an interaction, it becomes increasingly possible to help them have more productive conversations about tough topics. Helping each partner focus on their own individual interactional goals (for instance, responding with curiosity rather than defensiveness) will help them experience one another differently when they discuss their differences–as teammates and collaborators rather than adversaries. Creating positive experiences builds positive regard as well as goodwill and motivation. In the end, the couple will find themselves with the opportunity to build something MUCH better than either has ever imagined.

One question you can’t fail to ask your clients

I know from experience as a therapist how difficult working with desire discrepancy can be. Some of the most distressed, frustrated, angry, hurt couples I’ve worked with have been struggling with all the difficult feelings that come with mismatched desire.

There is just so much to be upset about. We invent a lot of stories about why one partner might want sex more often than the other, usually judgmental or dire things about ourselves, our partner, or our relationship. We feel trapped, frightened, depressed, and things start to feel complicated and tangled very quickly. The clients feel hopeless. After a few months of therapy, the therapist often begins to feel hopeless too. But I’ve worked hard to figure out how to be more effective with these couples, and I’ve developed some tools that make dealing with desire discrepancy much, much easier.

I want to show you how well these tools can work by walking you through a story from my therapy room. This is the true story of a couple that had almost given up hope of fixing their desire discrepancy, and how I was able to restore their hope within just the first ten minutes of my time with them.

When the couple walked into my office, they didn’t believe I would be able to help them.

I couldn’t blame them for that. Their relationship had been floundering for years as they bounced from one therapist to another. Their therapists, they told me, always wanted to talk about improving communication. This wasn’t unhelpful, exactly—they had learned to communicate better—but it failed to address the root of their distress. Even a sex therapist hadn’t been able to shift the problem. Over time, they had come to fear that their relationship was unfixable.

The wife was weeping in my office, blaming herself for not wanting sex. Why dont I want sex? What is wrong with me?  she wondered. Her husband wanted to be supportive, but he was afraid that his wife wasn’t attracted to him anymore, or that he was bad lover. I could feel their despair, and I wondered how painful it must be for them to live with these feelings, day‐in and day‐out.

But after I heard their story, I was able to determine within five minutes a very likely root cause of the desire discrepancy, a root cause which no other practitioner had brought up with the couple. With a few more minutes of discussion, I had explained my theory and made an appropriate referral. I was able to see hope begin to bloom between them, and they left my office so much happier than they had arrived.

How was I able to do this? By asking the right questions. Using the assessment tool I run through with all my clients, and which I share in my free video workshop, I was able to identify the root of the problem as unresolved sex pain.

Imagine what it must be like to have pain be a regular feature of the most intimate moments between two partners. Imagine the harm that can do to a relationship and an intimate connection. Imagine the strength of the love between partners butting up against the body’s wise and very adaptive drive to protect itself. How could desire possibly bloom?

The really sad aspect of this to me is that none of the therapists they had seen before had known to ask about sex pain! In my further questioning, the couple told me they had even consulted an ob/gyn and STILL they experienced unresolved sex pain. Of course, it is helpful to know how to work with sex pain, but that’s not rocket science. There are a handful of very common causes and there are specialists who work very effectively with most of those. There are also specialists whose job is to identify and treat unusual or difficult-to-treat causes.

But in this couple’s case, I was the first to ask about sex pain, form a theory based on the description of symptoms, and inquire whether they had consulted a pelvic floor physical therapist. When they did, the pain began to improve. Over the course of several months of steady improvement, their relationship recovered, buoyed by hope and positive results. Therapy with me simply supported this progress. The couple and the physical therapist did all the work.

Are you thinking “Sure, but she’s a specialist, I know nothing about sex pain and could never do that?” Not true!! I have explained to thousands of therapists, including generalists, specialists, and students, how to use my brief assessment tool and what to do with the findings. I am 100% confident that each and every one of them would have come to the same conclusion I did, and made the same referral.

You can too. If you haven’t already, sign up for my video workshop. It will help you get a strong head start dealing with any sex issue. And if you’re ready to go deeper, to begin helping clients ease distress in this extremely vulnerable area, consider giving my online course a try. It’s a full toolkit for assessing and treating sex issues, packed with robust, flexible interventions that you can put into practice right away. No matter your level of experience, it will help you stretch your limits, increase your potential, and grow as a therapist.