When to see a doctor, when a sex therapist, and when couples therapy is enough

“We went to the doctor first. He said the test results were all fine. Now we don’t know whether it’s us that’s wrong.”

Many therapists who work with couples hear a sentence like this. There is usually a long road behind it: a month or two when something started to creak, then half a year when nobody talked about it, then an awkward appointment with a doctor who examined what needed examining and said he could find no physical cause. The relief lasts a day. Then a new, harder question opens up: if it isn’t the body, what is it? And who do we go to now?

This piece is an attempt at a map. Not because the answer is always simple, but because people often get lost at the very first step — they don’t know whether their problem is for a doctor, a sexologist or couples therapy, so they go nowhere at all. Let me also say right at the start who is writing: I am a therapist in training under supervision in marriage and family therapy, training in relational family therapy. I am not a sexologist and I am not a sex therapist. In couples therapy, intimacy is often one of the themes we work with, but for sexual dysfunctions the right address is someone else. That is exactly why it feels honest to explain where each boundary lies.

Three doors we keep mixing up

When something goes wrong with sex, three different kinds of help are available. The names sound similar, but the questions they ask are very different.

Sexual medicine asks: what is happening in the body? This covers hormones, blood flow, nerves, pain, infections, the after-effects of childbirth or surgery, and the side effects of medication. The first address is your GP, then a gynaecologist or urologist, and where needed a specialist who focuses on sexual medicine.

Sex therapy asks: how was the problem learned, and what keeps it going? Even when it began in the body, fear, pressure, shame and avoidance often attach themselves to it and then carry on living by themselves. Sex therapy is a distinct field of psychotherapy with its own training and techniques aimed directly at the sexual response.

Couples therapy asks: what is happening between the two of you — in the bedroom too? It deals with the relationship in which sex lives: closeness and distance, resentments that pile up, the way you argue and the way you make up, the sense of whether it is safe to show the other person what you want.

The confusion arises because all three touch the same thing. If a man cannot get an erection, it may be a sign of vascular problems, a consequence of anxiety, or a response to a relationship in which he has not felt wanted for months. Most often it is a mixture. So the question “who should we see?” is not a question of who is right, but a question of order.

Why the body always comes first

Sexual difficulties are not rare, even though almost nobody talks about them. In a large American study published in 1999 by Edward Laumann, Anthony Paik and Raymond Rosen, 43 per cent of women and 31 per cent of men reported at least one sexual difficulty in the previous year. These figures come from another country and another time, but the message is simple: if you have a problem, you are not an exception.

And precisely because such problems are so common, it is easy to put them down to “the mind” or “the relationship” before anyone has looked at the body. That is a mistake. A study published in 2005 by Ian Thompson and colleagues showed that men with erectile difficulties had a higher risk of cardiovascular disease in the following years. An erection is a sensitive indicator of the state of the blood vessels and is sometimes the first warning sign of something that has little to do with sex. It is similar for women: pain during intercourse can be the result of an infection, changes after childbirth, hormonal changes or an illness that a gynaecologist needs to look at first. I have written more about this in Painful sex in women: when to see a doctor and when to see a therapist.

There is also something on the list that people often forget: medication. Some antidepressants, blood pressure medicines and hormonal contraception can affect desire, arousal or orgasm. Do not stop taking these medicines on your own — talk about side effects with the doctor who prescribed them. There is often an alternative. If you are curious how medication and talking therapy complement each other, you can read Antidepressants and therapy are not rivals.

Hence a rule I follow without exception: physical causes are checked by a doctor first. Your GP, a gynaecologist or a urologist. Even if you are convinced “it’s all in my head”. A result showing that your body is fine is not wasted time — it is the foundation on which we can then build differently.

What sex therapy is and what it isn’t

Sex therapy developed as a distinct field in the 1960s and 1970s. In 1970 William Masters and Virginia Johnson described a programme in which they worked with a couple on the sexual response step by step, using exercises that take away the pressure to perform. A few years later, Helen Singer Kaplan linked this with a psychodynamic understanding: sometimes an exercise is enough, sometimes there is an older fear beneath the problem that needs to be understood.

Today, sex therapy combines information, body-based exercises and conversation. It deals with issues such as premature ejaculation, erectile difficulties without a physical cause, inability to reach orgasm, fear of penetration or a large gap in sexual desire. Our understanding of desire itself has also changed: in 2000 Rosemary Basson described how, for many women, desire often does not appear before touch but during it — as a response to closeness. This is important news for many couples, because it shows that less spontaneous desire does not in itself mean something is wrong. A sex therapist has specific training for this work, which a marriage and family therapist does not have by default.

What sex therapy isn’t: it isn’t “fixing” one partner while the other waits outside. It isn’t a place where anyone demands what you must do. And it is no substitute for a medical examination. A good sex therapist will always ask first whether one has been done.

One simple stepped model that professionals have used for decades is called PLISSIT — from the initials for permission, limited information, specific suggestions and intensive therapy. The psychologist Jack Annon described it in 1976. Its message is reassuring for non-specialists: many people do not need intensive therapy, but someone who gives them permission to talk, tells them a few accurate facts and offers one or two concrete suggestions. Only when that is not enough is it time for a specialist.

What couples therapy does: the relationship in which sex lives

Couples therapy does not treat sexual dysfunctions. It deals with something else, which is nonetheless closely intertwined with sex: the relationship.

Sex is not an island. It lives in the same flat as the unpaid bills, the argument about who gets up to the baby, the feeling that the other person no longer sees you. When there is a lot of unspoken resentment between partners, the body is often the last thing still saying so. When one always initiates and the other always declines, sex becomes a battlefield on which each defends their own side. I wrote about how such a gap takes shape in When your desires don’t match: sex in a long relationship, and you can find a short explanation in the knowledge base under differences in sexual desire.

In couples therapy, then, sex is often discussed indirectly. Not what happens in bed, but what happens when one reaches for the other and is turned down. What they think about it. What they feel. What they do the next day. This cycle — reaching out, rejection, withdrawal, hurt — is not unique to sex. The same pattern often repeats when a couple talks about money, about their parents or about who forgot what. When it starts to resolve there, it often softens in the bedroom too.

When a couple learns to talk about what they need instead of blaming each other, room opens up for conversations about intimacy as well. I describe how this is built in From blame to needs: how a couple learns a new language.

How one problem spills over to both sides

In practice, the three doors rarely keep to their own corridors. Take an example therapists know well. A man is unable to get an erection a few times when he wants one. Perhaps because of tiredness, perhaps alcohol, perhaps for no clear reason. Next time he gets into bed with the thought: “What if it happens again?” That thought triggers tension, tension dampens arousal — and it happens again. What professionals call performance anxiety appears. This layer is the subject of Erection problems and the mind: when the body is not the main culprit.

Soon he begins to avoid it. He goes to bed later, breaks off a kiss before it could lead anywhere else. His partner doesn’t know what is going on. First she thinks something is wrong with him, then that something is wrong with her. That he no longer finds her attractive. That he has someone else. Because she doesn’t ask — or asks and hears “everything’s fine” — she withdraws too. Six months later they are a couple in which nobody raises the subject, and both are convinced the fault is theirs.

A couple like this needs all three. A doctor to check blood vessels and hormones. Perhaps a sex therapist to help with the fear of failing. And a conversation about what has happened between them over these months — about feeling rejected, about shame, about what they didn’t dare say. Shame is often key here: it doesn’t say “I did something wrong”, but “I am wrong”. More on this in the knowledge base under shame.

This is how the moment might sound when the subject is first opened up in a couples session (composite, not a real person):

“I thought you didn’t want me any more.”
“I didn’t know how to tell you. I was ashamed.”
“For six months I was guessing what I’d done wrong.”
“Nothing. I was afraid you’d be disappointed.”
“What hurt more than anything was that you went quiet.”

There isn’t a single word in this short exchange about technique or the body. And yet half the problem is in it. A doctor could prescribe a medicine, but it would not help their silence. And couples therapy can open the silence, but it won’t repair blood vessels.

Where to start: a short guide

If you don’t know where to begin, use this order. It isn’t a recipe, but it is a good start to a conversation with yourself and your partner.

A few pointers help with the second step. If the problem appears only with your partner but not when you are alone, the relationship is an important part of the picture. If it appears always and everywhere, even when you are alone, it makes sense to ask the doctor again or to see a specialist. If what stands out is fear of the act itself — of pain, of failing, of not being “enough” — sex therapy is probably the right path. But if sex was never really a problem for you until you started drifting apart, it makes sense to begin with the relationship.

One more thing: when choosing a professional, don’t go by title alone. Ask what training they have, what they work with and who supervises their work. That isn’t rude, it’s responsible. I have also described the difference between various professional roles in Clinical psychologist or psychotherapist: two roles we constantly confuse.

Exercise: notes before your first appointment

Many people fall silent in front of a doctor or therapist. The subject is intimate, time is short, embarrassment is great. This exercise helps you arrive prepared. You can do it alone or together with your partner.

1. Write down what is happening, in plain words. Not technical, not softened. “Sex hurts.” “There’s hardly any desire left.” If you feel awkward, imagine you are writing for someone who doesn’t know you.
2. Write down since when. Has it always been like this, or did it start with something — after childbirth, with new medication, after a move, after an argument that was never resolved?
3. Write down when it is better and when it is worse. On holiday? When the two of you are alone? When you are by yourself? After a conversation in which you felt heard?
4. Write down all the medication and supplements you take. Including those without a prescription. Take this sheet with you to the doctor.
5. Write down one question you want to ask. Just one. “Could this be because of my medication?” or “Is this something for you or for someone else?” Once it is on paper, it is easier to say out loud.

If you do the exercise together, let each of you write alone first and only then compare. It often turns out that partners see the same problem very differently — and that is valuable information, not a reason to argue.

Sometimes simply writing it down moves something that has been stuck for a long time. Once the problem is on paper, it is no longer a nameless shadow between you, but something you can talk about.

Where this map doesn’t hold

The order “body first, then relationship” is a good default starting point, but it isn’t a law. A few exceptions matter.

When there is no safety in the relationship. If your partner pressures you into sex, humiliates you or you are afraid of them, this is not a “sexual problem” and not a subject for joint therapy while the violence continues. Joint sessions can even do harm in such cases, because they ask the threatened partner to speak openly in front of the person threatening them. Then the first step is your safety. In Slovenia you can call the SOS helpline for women and children who are victims of violence on 080 11 55, and in danger 113 or 112.

When trauma lies in the background. If sex is linked to memories of abuse, it is often better to work individually first, at your own pace, and only later involve your partner.

When the problem has nothing to do with the relationship. Some sexual difficulties affect people who have no partner, or are present equally in every relationship. In that case couples therapy is not the right frame.

When the doctor finds nothing, yet the body isn’t “ruled out”. A normal result doesn’t always mean everything has been explained. Body and experience are more intertwined than we like to admit, as I describe in “The tests are normal, but it still hurts”: what therapy knows about psychosomatics. If the pain or difficulty persists, it makes sense to seek a second opinion.

And one more trap, which I see as the most important: the idea that couples therapy might simply “be enough”. Couples therapy is not enough in place of a doctor or a sex therapist. When the relationship is the main part of the problem, it is the right choice. When it isn’t, it may be one of three paths running side by side.

What you can expect if you come to me

Since this piece is about choosing, it is only right that I am clear about myself. I work with couples in person in Ljubljana, as a therapist in training under supervision in marriage and family therapy, and I also work with English-speaking clients. Sex is not a forbidden subject in our sessions — on the contrary, it is often an important part of the story a couple brings. We will talk about how your closeness and distance show up in it, what happens when one of you reaches out and the other declines, and how it is possible to talk about this without blame.

What I won’t do: I won’t diagnose sexual dysfunctions and I won’t provide sex therapy in the narrower sense. If during our work I notice that you need a doctor or a specialist in sexual medicine or sex therapy, I will tell you so and encourage you to seek that help too. The two paths often complement each other well. If you are not sure whether couples therapy is the right step now, you may also find When to start couples therapy: signs you need help before it is too late helpful.

Talking about sex requires vulnerability — the willingness to show what matters to you without knowing how it will be received. You can find a short explanation of this concept in the knowledge base under vulnerability. My task is to make the space safe enough for that to happen.

What to remember

• Sexual medicine, sex therapy and couples therapy ask different questions: what is happening in the body, what keeps the problem going, and what is happening between you.
• Physical causes should always be checked by a doctor first — your GP, a gynaecologist or a urologist — even when you are convinced “it’s all in my head”.
• The same problem often has several layers at once; help on one side doesn’t rule out help on the other.
• Couples therapy works with the relationship in which sex lives, but it does not treat sexual dysfunctions.
• When there is no safety in the relationship, your safety comes first, not joint therapy.