When Sex Is the Issue and When Sex Is the Symptom

Sex is a drive complicated by internal and relational needs.

Reviewed by Tyler Woods

Sexual matters and sexuality are always present in the consultation room, particularly if you practice from a psychodynamic (insight-oriented) framework. Whether the patient seeks help specifically for sexual problems, for other relationship issues, or for anxiety or depression, sexuality is omnipresent. And yet, many individuals and couples never discuss and are never asked by their therapist about sex or their sexual behavior.

Psychodynamic therapists see sex as an integral part of human nature and relationships. What role it plays is the exciting work of in-depth psychotherapy. Sometimes, there is overt conflict regarding sexual attitudes and behavior; sometimes, sex is a metaphor, running parallel with other intimacy and relational issues, and sometimes, sexual symptoms appear as representations of deeper individual conflicts yet to be understood.

Sexual symptoms can be the result of medical conditions. When we have a symptom, we seek a concrete solution to what ails us. Premature ejaculation, painful intercourse, anorgasmia, inability to obtain or maintain an erection, or sexual boredom open the door to exploration.

First, medical disorders with sexual symptoms are identified and ruled out, like vascular and heart disease. Hormonal imbalances diminish arousal for both men and women. However, when the medical evaluation is complete and no underlying medical issue explains sexual symptoms, we turn toward other causes.

Occasional use of prescribed sexual performance drugs works. Dependency on these drugs is a pharmaceutical's dream and health care nightmare; reliance on sex drugs increases over time and is reinforced by anxiety about performance when faced with another sexual encounter, particularly among younger men. Introspection is too time-consuming; it can be challenging and shameful when the sexual symptom is not medical but rather psychological.

A meta-analysis review found that combined interventions of sexual performance drugs were significantly superior to medical treatment alone. In comparing Psychological Intervention to sex drugs like Tadalafil and Sildenafil, two studies found the psychological intervention to be significantly superior to medication. In three studies, psychological intervention was significantly superior to no treatment. (Attalah, I.)

Mental health...a plethora of approaches

In an ever-increasing culture of the pursuit of a quick fix for whatever ails us, immediate solutions for sexual symptoms generally are a challenge for mental health therapists to manage patient expectations. Sometimes sexual issues 'simply' require 'sex therapy,' and typically, some form of cognitive therapy is appropriate.

Cognitive Sexual Therapy (CST) integrates behavioral techniques and changing cognitive processes like poor communication due to shame, misinterpretations of the partner's response, distorted sexual views based on a lack of understanding, and the body's arousal curve, essentially how genitalia work. CST aims to restructure cognition toward acquiring skills (techniques) and implementing them toward more positive sexual experiences by regulating negative feelings, anxiety, and thoughts.

Often, however, sexual issues are more complex than can be treated with CST. Sexual symptoms reveal deeper issues, including sex and non-sexual matters, which involve longer-term psychotherapy.

"Internal psychological processes are influenced by the spectrum of social, intrapsychic and relationship factors which can precipitate conscious and unconscious reactions to the sexual experience." (Daines. pp 23.)

Psychoanalysis informs us that sexual symptoms arise in response to unconscious conflict. Freudian thinking is still relevant; modern-day psychoanalytic theories emphasize that human behavior is motivated by aggression and the seeking of sexual pleasure. The psyche constantly struggles with these instincts (drives) in the pursuit of expression and gratification while adapting to relational and societal norms and prohibitions.

Psychoanalysis maintains that the demands of society are in inevitable opposition to the individual's needs and, as the individual is dependent upon the wider group, repression, and neuroses become the price the individual has to pay to fit into society. (Daines. Freud. Arlow. ) "The symptoms of neurosis (like anxiety, phobias) represent either a substitute satisfaction of some sexual impulse or measures to prevent such a satisfaction and are, as a rule, a compromise between the two." (Freud.)

Psychodynamic theories view sexuality as a cornerstone to identity - the fabric from which we are cut; they focus on how we convey our sexuality in relationships and differ from conflict being housed solely in the individual, as psychoanalysis frames it. Conflict arising in response to relational needs, dependency, and the risk of rejection, abandonment, disapproval, and others' anger is the focus framework within a psychodynamic approach. Similar to psychoanalytic thought, the psychodynamic framework emphasizes the conflict or tension that exists between societal norms and attitudes about sex communicated by caregivers during childhood with a person's inner desires, wishes, and fantasies. Conflict typically emerges when there is guilt, shame, and prohibitions about how we desire and are expected to behave. Symptoms appear, i.e., erectile dysfunction or lack of arousal in women, as the vehicle through which the conflict is demonstrated; symptoms are the physical manifestation of a conflict whose origins are generally sexual, although they can be related to other states such as aggression, anxiety, and guilt as well. (Corretti)

Psychodynamic theorists accept that sexual gratification, deprivation, and dysfunction are phenomena that affect the whole self-image, and the self-image often affects sexual functions. (see HS Sullivan, Guntrip, Horney.)

For example, Joe, a hypothetical patient, has had mostly satisfying sexual experiences throughout adulthood. Joe recently started a new relationship and finds himself unable to "perform" sexually. Discussing Joe's new relationship reveals he distrusts his new partner's sincerity and capacity for genuine connection. His body, in effect, speaks for Joe; his erectile failures are the outcome of not wanting to share himself (his penis) with her.

Interpersonal theories focus heavily on relationships and see sexual dysfunction as the symptomatic expression of a conflict whose origins may be rooted in childhood and repeated in adult relationships.

For example, Nancy and Sam have been married for ten years and have routine and perfunctory sex. Nancy wants Sam to be more "aggressive" in bed, and Sam wants Nancy to be more seductive and interested. Analysis reveals that Nancy had a dominant and aggressive father who, although excited Nancy, was also threatening. Sam, on the other hand, reveals growing up in a 'gray' world with two parents who were depressed and complained regularly. There was little enthusiasm and playfulness in his household. It is not difficult to imagine how these childhood issues result in unfulfilled sexual responses, behaviors, and fantasies for them. Nancy negated Sam's efforts, who was indeed assertive but not aggressive. Sam's fantasy about what sexual excitation meant, based on watching porn, was an exaggerated and immature notion of sexual eroticism. Their sex life was stuck because they had not matured past the developmental arrests from childhood.

The CST therapist might focus on improving sexual communication and techniques to assert what one's needs are in the moment, establish realistic expectations, and have reliable communication. CST might address familial behavior and educate the couple about mature and erotic lovemaking.

A psychodynamic therapist analyzes the present context, using the symptom as a voice for the person's unconscious feelings or childhood conflicts. Through questioning and interpretation, the therapist facilitates Sam's wish to fix the lack of childhood joy and excitement. Nancy attempts to master the threat from her father's volatility and domination through conflating aggression and assertion.

In my experience, insight, understanding motivation, and interpretation of unconscious processes provide a more meaningful relationship with sex.

To find a therapist near you, visit the Psychology Today Therapy Directory.