Sexual Health


Women and men rarely ask their family therapist to help them improve their sexual health. More than likely, people are concerned about their sexual behavior, sexual satisfaction or the lack of sexual pleasure. Couples will often seek therapy to address conflicts about sexual frequency, sexual desire and the fallout after an affair. Changing unwanted consequences of sexual behavior may be highly prevalent motivations for seeking therapy, however they make up just a small component of the much larger concept of sexual health. 

Sometimes women and men come to therapy to examine confusing discrepancies between their sexual behaviors and their spiritual and ethical values. Adults, couples, and families avoid talking about many sexual matters until the consequences a family members specific sexual activity are discovered and can no longer be avoided. In many families, parents may find it difficult to address common sexual development milestones such children masturbating, going through puberty, attractions, falling in love and the first intercourse. 

Up until the middle of the last century sexual health meant two things: avoiding an unwanted or unplanned pregnancy and not acquiring a sexually transmitted disease. Since at least 1974, the World Health Organization (WHO) and other health organizations began to develop sexual health definitions beyond avoiding STDs and unwanted pregnancies.the clap getting knocked up. Now, sexual health encompasses a society in which each person is guided in having a safe and pleasurable sexual life beyond the mere absence of the unwanted consequences of sexual activity or sexual intercourse. 

The current WHO working definition of sexual health encompasses human rights related to sexual health, sexual pleasure, eroticism, gender and sexual relationship diversity, sexual satisfaction, diseases (HIV/AIDS, STIs, RTIs), violence, female genital mutilation, sexual dysfunction, and mental health related to sexual health. Sexual health is now considered as one of the four pillars of health: Physical, Mental, Spiritual and Sexual.

Sexual health can be understood as a set of principles that integrate personal values, ethics, religious beliefs, cultural norms and unconventional sexual interests or practices. Six sexual health principles (adapted from the WHO definition) construct a broad international set of minimum ground rules upon which each person can come to know their own specific individual vision of personal sexual health (Braun-Harvey, 2009). The six principles of sexual health provide a map to balance couples and family conversations about sexual activity, sexual functioning, and sexual relationships before it is a problem or hurts someone. 

 Think of these six principles of sexual health as aspirations and goals for living your sexual life in such a way that you feel proud and can create sexual self-esteem for yourself and those you love.

Written by Douglas Braun-Harvey

Consent Sexual health requires sex to be consensual. This is the most universal sexual health principle on the planet. Consent means “voluntary cooperation” (Wertheimer, 2003, p. 124) and communicates permission to try and reach sexual satisfaction and intimacy with willing partners. The age of consent varies by country, and in the U.S. varies by state. Non-consent forces children and adults into sexual experiences that are not desired or wanted. This sexual health principle is most commonly violated in the victim’s home in circumstances of child sexual abuse, sexual assault, and rape. 

Consent transforms the act of sex from an invasion, intrusion or violation into an act of transformation. Establishing consent throughout each step of a sexual interaction provides each sexual partner space for sexual safety and pleasure that is consistent with their sexual desires. When consent is given, one is saying, “I want this experience to have an effect on me, to change me, to give me something that I desire, and I want you to provide it for me.” 

Non-Exploitative Sexual health requires sex to be non-exploitative. Exploitation is when a person leverages their power and control to receive sexual gratification. The cruel brutality of exploitation compromises a person’s ability to consent to sex. Exploitative sex unfairly makes use of someone for sex. People under the oppressive influence of exploitation may be faced with placing themselves in more danger if they chose to say no to sex. Exploitative sex is ruthless and insensitive to the feelings of a partner and family members. Exploitation encompasses unwanted harsh or cruel domination or taking advantage of a person who is mentally incapable to use their cognitive and emotional capacities to give or not give consent. Intoxication is often used as an excuse to be exploitative. Money, drugs, clothing, shelter, or love are often situations in which a person will use coercion to gain access to sex. 

Members of a couple will each bring their individual sexual histories of both exploiter and exploited. The most common form of sexual exploitation that motivates people to seek out marriage and family therapy is when one or both partners unilaterally changes the couples’ sexual agreement. (usually called an affair, cheating, stepping out, or betrayal). The exploitation is the cover-up, the denial, the pretending this did not happen and exploiting their partner’s trust. Emotional affairs and cheating are common reasons for couples to seek out a marriage and family therapist. 

Honest Sexual health requires open and direct communication with oneself and every sexual partner. Honesty with oneself involves being open to sexual pleasure, sexual experience, and sexual education. Without honesty, sexual relationships will not be able to have effective communication or be able to uphold any of the sexual health principles. Honesty encompasses sexual health conversations about gender and/or sexual relationship diversity. Each person has the responsibility to determine their own standards of honesty about sex and sexuality as it relates to their partners, medical providers, community, and themselves. 

A sexual health conversation tip: when you’re surprised by a sudden question about a sexual matter from a child or teen, you can give yourself a few extra seconds to compose yourself by taking a deep breath and first thanking them for their honesty and asking a question about sex. They will remember that some adults welcome their honesty, a lesson that they might benefit from throughout their life. 

Shared Values The day after a dolphin has sex, they don’t spend the next day talking with their fellow dolphins about whether it was “too soon.” Humans do. Children, teens, and adults of all ages think about their values and how they relate to experimenting with sexual activity, entering sexual relationships, or facing gender and sexual relationship diversity. 

Too often the caring adult’s discomfort or conflicted values about child and adolescent sexual questions leaves youth without important sexual health conversations that help them build a sexual values system of their own. One of the most universal areas of sexual value conflict is the sexual debut (usually called losing one’s virginity). There is no universal cultural agreement about the circumstances upon which a person should first experience sexual intercourse. 

Throughout the lifespan, sexual values play an important role in motivations for sex. Specific sexual acts or turn-ons may have very different meanings for each partner. Values are a source of identifying one’s sexual standards and ethics. Values differences, when honestly and vulnerably shared between partners, can lead to closeness or painful distance. Either way, it is a conversation that brings reality and clarity where couples may have previously chosen avoidance and deception.

Protected from STI, HIV, and Unwanted Pregnancy This sexual heath principle addresses the need for anyone engaged in sexual activity to implement a contraception plan, prevent acquiring a sexually transmitted infection and take precautions to prevent transmission of HIV. Access to tests that identify the presence of a sexually transmitted infection and proper medical attention to address any infections is essential for sexual health. Scientific and medically accurate information regarding how to prevent pregnancy requires access to a range of contraception methods. Latex condoms, medical adherence to HIV medications, and taking PrEP (pre-exposure prophylaxis) are essential ingredients for protecting ourselves and others from HIV infection. This is a time of increasingly reliable and effective forms of contraception as well as HIV prevention. Lack of medically accurate information about these excellent sexual health protection resources is a much larger problem. For example, less than 20 U.S. states require that the sexual education provided by federal and state funding be medically accurate. This means that even when a child or teen is fortunate enough to have school based sex education, chances are the content of the class is not supported by sexual science unless the state has laws ensuring this sexual right. 

Pleasure Pleasure is a primary motivation for solo-sexual activity (masturbation) and the giving and receiving between sexual partners. What gives us sexual pleasure is often a source of conflict when our pleasure conflicts with other aspects of our overall private and public identity. A married cisgendered heterosexual identified woman may find peak sexual pleasure dominating a submissive trans man that she has no emotional connection with other than the immediate moment of power exchange and erotic exploration. Too often judgments about the lack of congruence between what we are expected to find pleasurable competes with the erotic demands of our most hungry sexual desires. 

Pleasure is a primary motivation for solo-sexual activity (masturbation) and partnered sex. Adolescents interested in experiencing their bodies sexual pleasure either alone or with another person challenges many adults who love and care for teens. Engaging in conversation, education or accurate information with teens about sexual pleasure is typically avoided. When caregivers do have a conversation it too often emphasizes the adult’s values and judgments about teens and sexual pleasure. (i.e. they’re too young to truly understand how to feel pleasure, or they’re not ready to have sex at all, they should wait until they are older, or they should never masturbate). Throughout all stages of life from pre-teen to the final years of life, sexual health is the art of balancing one’s sexual safety and responsibility with the lifelong curiosity of pleasure, exploring sexual interests and remaining curious about the ever-changing sources of sexual pleasure.

Most therapists are experienced with guiding discussions about the negative consequences of non-consent and exploitation (mental health professionals are expected to discuss sexual risks, consequences, and dangers). Choosing a therapist who can address both sexual safety and sexual pleasure is important when the reason for seeking therapy is related to any of the sexual health principles. Therapy that addresses sexual health facilitates clients discovering how they can create a more balanced life of sexual pleasure and sexual safety. 

Facing adolescent sexual pleasure motivations can be challenging for many adults. Too often caregivers emphasize their values and voice their judgments about teens wanting to experience pleasure. (i.e. they’re too young to truly understand how to feel pleasure, or they’re too young to have sex at all). This also addresses “solo sex,” as masturbation is often the first sexual experience many of us have, in addition to the most common.

Find a Therapist

If you or someone you know is experiencing distress, therapy with a marriage and family therapist (MFT) can help.

Find an MFT

Understanding the Benefits of Marriage and Family Therapy

What distinguishes MFTs/family therapists from other mental health professionals?

The training of of MFTs includes live supervision by experienced MFTs, which is unique among the behavioral health disciplines. This highly accountable training focuses on the unique attribute of MFT treatment which is the heightened sensitivity between you and those in your environment (family members, coworkers, friends) and how these relationships can help or challenge you and your experienced problem areas. 

Sexual problems cannot be swept under the rug without negative emotional consequences, nor do they just disappear like the common cold.

Effect on Couples and Families 

Because sexual health encompasses both physical and emotional well-being, problems with sexual health can significantly disrupt normal functioning for an individual, partner, and the family. For example, issues in a relationship such as power imbalances, resentment, and anger can reduce how much desire one has for his or her partner. Communication problems within a relationship and an inability to talk about how to meet sexual needs can also impact a couple’s ability to be sexually healthy. Couples also may fear being close to one another, which will also reduce their desire. Further, relationships that are not sexually healthy may unwittingly communicate a negative message about sex to other members of the family, such as “sex is bad,” or “sex is something that should not be discussed.” Such messages can impair the future generation’s ability to enjoy sexual health without guilt and shame. Further, negative attitudes and models in our culture also influence one’s view of a sexual problem, and these attitudes can unknowingly be communicated to your partner or other family members if sex is not discussed or is viewed as shameful. Negative views create an environment where sexual issues are difficult to discuss with others without shame or embarrassment, and can potentially lead to a feeling of greater isolation by the individual or couple. 

In relationships where couples do not openly communicate about sex, the effects can devastate the relationship. Sexual problems cannot be swept under the rug without negative emotional consequences, nor do they just disappear like the common cold. Unfortunately, we know that the majority of couples do not seek help. 

Several reasons people avoid getting help include: 

  • Hoping the problem will resolve or disappear after time 
  • A sense of stigma or embarrassment that they are the only ones with the problem 
  • Having low sexual expectations 
  • Feeling hopeless about the problem and being skeptical that therapy can help 
  • Simply being unable to identify a problem as a problem (for example, men with premature ejaculation often think it is normal) 
  • Having difficulty finding a marriage and family therapist who is credentialed in sex therapy and is affordable

Signs of a Sexual Health Problem 

The signs of the deterioration of sexual health are often subtle because of the embarrassment one might experience in calling attention to the symptoms. For example, an individual may notice symptoms, such as loss of desire or an inability to achieve orgasm, but these will be personal and not necessarily noticed or shared by one’s partner. Further, the individual experiencing the symptom may try to explain it away, perhaps attributing the cause to acute stress, recent developments within the couple’s relationship, or aging and other biological changes.

Common sexual concerns include: 

  1. For men: 
  • Trouble achieving and maintaining an erection 
  • Delayed ejaculation (which can cause relationship disappointment and distress) 

     2. For women 

  • Trouble reaching orgasm 
  • Pain during intercourse 
  • Lack of desire  

Other signs of deterioration have to do with the couple’s relationship. These signs may include discord around choosing a time to have sex that is convenient for both partners; approaching your partner indirectly or roughly; not communicating adequately or being clear about your request; being sexually inhibited; and too little foreplay and afterplay.

Seeking Help 

In identifying when to seek help, one suggestion is to seek help as soon as you notice a concern. Because a sexual relationship is embedded within a couple’s overall relationship, problems with sex can cause and be caused by other relationship problems. Left unattended, a relationship can slowly begin to erode. You can also seek help if any of the following conditions are present: 

  • Unhappiness with how often sex occurs 
  • Problems achieving or keeping an erection 
  • Inability to delay ejaculation until both partners have had their needs met 
  • Inability to experience an orgasm (either with your current partner or any partner) or dissatisfaction with orgasms you have 
  • Pain during intercourse Fear of developing an intimate, close relationship with your partner 
  • Lack of desire to engage in sexual activity 
  • Unexplained change in your sexual needs/behaviors  

Creating a positive sexual environment is based on sharing emotions, affection, and being with each other in a way that allows for sexual feeling to emerge. While there are a host of interventions that therapists use to improve a couple’s sexual health, there are several basic ones. The first is education. Comprehensive sex education has been shown to have a number of benefits, such as improved self-image, comfort with sexuality, open communication with parents and others, and avoidance of risky sexual behaviors that can lead to pregnancy and sexually transmitted infections (STIs). Effective human sexuality education has many purposes. Good education about sexual health includes: scientific information, fostering positive attitudes, values, and insights, teaching relationship and interpersonal skills, and how to assume sexual responsibility. A positive sexual attitude would help one develop positive feelings about body parts, experiments with appropriate sexual self-exploration, and is free of sexual inhibitions later in life that impede having healthy sex.

Choosing a Therapist

Be sure to ask how your therapist was trained to guide and discuss sexual health in terms of the negative consequences of non-consent and exploitation (we focus on risk, consequence, danger). Sexual safety is emphasized and remains out of balance with talking about how to create a life of sexual pleasure and sexual safety. This is often reflected when youth and adults seek help for experiences like sexual abuse, assault, rape, etc. Your therapist may use trauma focused cognitive behavioral therapy to integrate both sexual safety and sexual pleasure.  

It is important to evaluate a therapist’s comfort, ability, and willingness to engage in meaningful and informed psychotherapy sexual health conversations as part of choosing a therapist. Too often a client and therapist will delay even discussing sex, no less the vulnerable interpersonal space of pleasure, until it is way too late to discuss the therapist’s sexual health conversation skills related to pleasure. Sex therapy-credentialed marriage and family therapists are highly trained in an understanding the wide range of diversity human sexual pleasure. Sexual problems that arise from disgust, shame, fear, judgment, or ignorance about specific pleasurable sex acts can be effectively resolved a relatively short period of time (with the exception of desire problems, which can take longer). Make sure your therapist conducts a thorough assessment and collaborates with you to identify all the factors contributing to your sexual pleasure problem. In addition, because concerns about sexual pleasure rarely occur in isolation from other relationship issues, the marriage and family therapist can assist the couple with the general issues first before moving on to the specific sexual pleasure concern. Achieving healthy sexuality in the couple relationship could refer to each partner assuming mutual responsibility for his or her sexuality, being well-informed and educating oneself through a variety of books, classes, and online resources, being able to communicate openly and spontaneously, being open to sexual pleasure and exploration, and having a sense of passion and sexual desire. Of course, these elements are based on the fact that the couple has a relatively healthy relationship in general and is in fairly good health. When relationship discord does exist, it is important that the couple attend to these issues in order to address the impact on specific sexual areas of their life.

Achieving healthy sexuality in the couple relationship could refer to each partner assuming mutual responsibility for his or her sexuality, being well-informed and educating oneself through a variety of books, classes, and online resources, being able to communicate openly and spontaneously, being open to sexual pleasure and exploration, and having a sense of passion and sexual desire. Of course, these elements are based on the fact that the couple has a relatively healthy relationship in general and is in fairly good health. When relationship discord does exist, it is important that the couple attend to these issues in order to address the impact on specific sexual areas of their life.