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.

What Everyone Needs to Know About Painful Sex

Sex shouldn’t hurt. Too many people believe that having some pain with vaginal penetration is normal and to be expected. That’s simply not true. NO ONE should be having painful sex–unless it’s the kind of pain that is desired and negotiated in advance. Pain with sex is not something you just have to put up with. And, almost always, it can be resolved with a little help.

If you ignore sex pain and keep engaging in the painful action, it will almost certainly lead to worse issues down the road. And besides the physical damage, nothing will tank your libido like engaging in sex with unwanted pain. Every time you grit your teeth and keep doing the thing that hurts, you’re forging a link in your brain between that activity and pain. Over time, as sex and pain become more closely linked in your mind, your desire for sex will wane.

This is important to recognize, as one big reason that people continue to engage in painful sex is to avoid hurting their partner’s feelings or because they feel obligated to provide sex as part of their relationship. Even if simply grinning and bearing it will keep your partner from feeling rejected or uncomfortable in this moment, continuing to engage in painful sex will do your sex life more harm than good in the long term. And I suspect your partner would actually want to know. Hopefully, they want to do whatever is needed to help you have enjoyable sex.

The first step is to have that awkward conversation now. Let your partner know what you are experiencing, and that you’d like to see what can be done to help improve your experience of sex by decreasing pain. Be sure to let your partner know this is almost always something that can be resolved.

The second step is to stop participating in the activity that hurts. This is a temporary measure to make sure your body’s natural protective response doesn’t make the issue worse.

The next step is unravelling what’s going on with your body, with the help of a medical practitioner, a sex therapist, or both. There are countless potential causes for sex pain. You can start by using a high quality lubricant, and also consulting with your primary care physician. But be aware (your doctor may not be!) that resolving many issues requires the help of specialized professionals, like a pelvic floor physical therapist or a vulvar pain specialist. If your doctor doesn’t suggest one of these specialists, and your sex pain doesn’t resolve, ask your doctor for a referral to a pelvic floor PT and let them advise you on how to proceed.

If you are feeling frustrated and things aren’t improving, consider consulting with a sex therapist, who can help sort out the issues and refer you to the right resources. With the help of skilled professionals and a little bit of patience, regardless of whether painful sex is new for you or something you’ve been living with for a long time, you are very likely to uncover the cause, resolve it, and start having pain-free, enjoyable sex.

It is also important to recognize that while you are working to resolve painful sex,  your sex life doesn’t need to grind to a halt. You can’t engage in the activity that produces pain–but there are plenty of other ways for you and your partner to create pleasure and experience closeness, which is (at least as I see it) what sex is really about. There is no reason your relationship has to suffer just because one activity isn’t possible for the moment. Situations like this one are the reason I often say that flexibility is the key to a happy, healthy sex life. This is an opportunity to work on that flexibility, and perhaps even discover new ways of connecting intimately that can become favorite additions to your sexual repertoire.

Should You “Just Do It” To Fix A Desire Discrepancy?

The conventional wisdom about desire discrepancy in a relationship is “just do it.” I’ve had many clients whose previous therapists have recommended some version of this approach, ranging from “ice-breaker sex” to “it’s like doing the laundry; sometimes you just have to get it done”.

I get that when a couple hasn’t had sex in a long time, it can become difficult to find a way to connect, get started, get vulnerable, or initiate intimacy. People frequently ask me “Where do we start? We’ve forgotten how to find one another”.

The problem is that desire can be a fragile thing, in need of a gentle touch. When desire is fragile, tentative, small, or hesitant, it can very easily tilt over into aversion if emotional pressure is applied, or even perceived.

So, what’s the difference between a tentative sexual encounter that results in a stronger connection, and one that has the unintended consequence of creating an aversion, or increasing anxiety?

Willingness.

Willingness is the crucial ingredient that is required for a sexual interaction to be a positive experience. Notice that I didn’t say “desire.”  In fact, desire is optional. Willingness is NOT optional. In order to run the experiment of trying to connect sexually after a dry spell, both partners need to feel willing. They might also feel worried, anxious, concerned, shy, tentative, vulnerable, embarrassed, or anything else. But as long as they are able to identify willingness, there is a good chance the interaction will be successful.

Here are some questions you might ask yourself to help yourself get in touch with willingness:

  • When sex goes well, how do I feel about myself?
  • When sex goes well, how do I feel about my partner?
  • What do I want to express to my partner sexually?
  • What makes a positive sexual interaction for me? How do I help create that?
  • What types of intimacy sound fun to me right now?
  • What types of intimacy would I prefer to postpone for another day?

Remember, you don’t have to do everything all at once. Consider inviting your partner to do something that sounds fun to you. Let them know, for now, your experiment is to keep it simple and stick with what you’re most comfortable with.

If you would like to have a conversation with your partner about having sex, try taking turns with these conversation prompts:

  • A part of me wants to have sex because….
  • A part of me is not so sure about having sex, because…

Make sure both of you respond to both prompts, so you don’t reinforce a polarized dynamic. Then see if you can work together to come up with a strategy to help you both get something you want from the interaction, while helping one another feel as little anxiety as possible.