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Key points
- Many concerns present as “sexual" but are really about self-esteem, communication skills, and self-acceptance.
- Most sexual concerns can be successfully addressed by any good therapist who’s comfortable with sexuality.
- If someone can’t stand their mate's behavior, sexual difficulties are typically not far behind.
America’s culture wars often focus on sexuality, but most people’s sexual concerns are far more pedestrian.
Unfortunately, most psychologists and physicians have little or no training in helping patients with common sexual issues. Sex therapists do, of course, but there are only a few thousand in America, and most Americans don’t even know the specialty exists.
As a sex therapist with over 40,000 hours of working with couples and individuals, I can actually answer the question: what are the central sexual concerns of ordinary people? Here they are:
1. "I’m concerned that my sexual fantasies aren’t normal. Or that they mean something bad about me. How much fantasizing is OK? And is it OK to fantasize in order to climax with my husband?" Most people don’t realize just how common and relatively tame their sexual fantasies are. Very few people fantasize about their mate—because why fantasize about something if we can already get it in real life? Taboo is the name of the fantasy game: activities and partners you “shouldn’t” do, risking serious consequences you’d never gamble with in real life.
Most people know that their non-sexual fantasies aren’t dangerous—whether it’s robbing a bank and moving to Tahiti, or killing a merciless boss and getting away with it. Similarly, most sexual fantasies have very little predictive value. “Interpreting” sexual fantasies is a parlor game that no one should take seriously.
2. "How do I cope with the sexual changes brought by aging?" In a youth-obsessed culture, it’s no surprise that people see virtually every age-related life change as bad, or something to postpone or prevent. If we can acknowledge age-related sexual changes, we can then think clearly about which changes to accept, which to manage, and which to oppose. Taking longer to get aroused, for example, is only a problem if you budget too little time for a sexual encounter.
3. "I’m in love with a great person, but we’re sexually incompatible. What should I do?" Contrary to some stereotypes, half of those with less desire than their mate are men, not women. Given cultural ideas about norms and stereotypes, this can create extra difficulties for lower-desire men and higher-desire women.
Like every other part of our personal makeup, sex drive (libido) is distributed among the population—some people are lower, some higher, some medium. For some people, libido varies a great deal depending on mood, personal hygiene, the state of a relationship, and, oh, the phase of the moon. For others, their desire (whether low or high) is stable regardless of circumstances.
Many people have enormous desire for one person, but very little for another. This isn’t a special orientation, it’s the way people have always been. That’s because desire is the product of dozens of factors—biologic, psychologic, and situational.
If two people are both content with very little sex, that’s fine. And if both value sex highly, and enjoy each other sexually, that’s also fine. It’s when two people with very different sexual personalities couple up that problems arise. And for reasons that no one can understand, this is very, very common. Maddeningly (and sadly) common, if you’re a therapist.
While higher-desire people can lose much of their drive if circumstances collapse, lifelong lower-desire people generally don’t become high-desire people. And when a “mixed” desire couple runs into problems, these problems can’t always be resolved.
4. "How do I get my partner to touch me or make love with me differently? What do I say when he asks why I won’t do a certain thing in bed that he really wants?" After people are together for a while, they learn each other’s eating preferences—how spicy they like food, whether they like their meat rare or well-done, if they eat vegetables enthusiastically or grudgingly. Do they drink water with meals? Coffee or tea afterward? What about dessert?
The same should be true about sexual preferences: What does Rosie like all the time, some of the time, or never? How much does Marcus like to be pushed into doing something? Nobody likes everything, and nobody likes the things they like to a uniform degree—when a person’s had a good night’s sleep and their chores are done, they may be more enthusiastic about sexual activities they’re often ambivalent about.
Communication really is crucial: Are you willing to tell the truth about your sexuality clearly, ask for what you want, and say no when you want to—all without apology? If you do, and your partner refuses to honor this, you don’t have a sexual problem—you have a relationship problem.
5. "I have a sexual dysfunction—now what?" First, let’s define “dysfunction.” Everyone has conditions that are necessary for our bodies to desire and respond sexually. Healthy people don’t get aroused when they’re angry, hurt, or scared. Healthy people don’t desire activities that they think they won’t enjoy. These situations are not “dysfunctions.”
Performance anxiety accounts for a lot of disappointing sex, such as loss of erection. Anxiety is best treated by therapy, with or without medication. It’s among the sexual conditions with the best outcomes.
Sometimes medical issues like diabetes, Hashimoto’s, osteoarthritis, or medication side effects lead to sexual dysfunction. A physician may be slow to discuss the sexual aspect of a health condition—which means the patient has to raise the subject.
The very first step is to discuss your concerns with your partner—not as a quarrel, but as a recurring situation that needs your joint attention.
6. "I’m afraid my partner is cheating on me," or "Years later, my partner still can’t get over my infidelity." Cheating and infidelity are among the most common cases I deal with every single week. Some people are chronically suspicious and eventually drive a faithful partner away. Other people are in low-sex or no-sex marriages and eventually feel they’re out of options—especially when no sex also means no affection.
“Too good to leave, too angry and hurt to want to stay” is a common dilemma after infidelity is discovered or disclosed. I tell people not to rush—they’ll go through lots of emotions in the first few months, which need to get sorted out.
Some people never get over a partner’s infidelity, almost as if they were waiting for it their whole lives. And now that the worst has happened, they plan to be so vigilant that it can’t happen again. Except that vigilance can’t prevent betrayal. It can only prevent reconciliation.
The typical responses to feeling betrayed are the same regardless of someone’s sexual orientation or identity. The pain of infidelity (on both sides of betrayal) is an opportunity to grow and learn about yourself. It’s an opportunity that nobody wants, but trying to get through infidelity without growing is a wasted opportunity—and it limits the possible outcomes of the crisis.
To find a therapist, please visit the Psychology Today Therapy Directory.
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