If I had to estimate, about a third of my clients wish they wanted or enjoyed sex more, about 10% would prefer less sex, something like 20% worry that they’re too into sex, and about a third of my clients are content with their libido and current sex lives.   

I generally have really smart clients who a) are invested in therapy and b) will research anything and everything in a methodical way — how to negotiate a raise, install a ceiling fan, sleep train a child, etc.  But some of these same folks will neither raise the issue of sex in sessions nor do much intentional research beyond talking to friends, Google/Buzzfeed/Reddit-ing it, or querying porn.

All of those options can offer some guidance and inspiration.  However, if you’re among the majority of people who are not thrilled about how sex is going, I encourage you to bring it up in therapy and/or read some of the following scholarly yet accessible books for a deeper take.  Because your experience might be different than your friend, or that of Reddit user “perfectstubble”.  And because porn has many virtues but illuminating the emotional, psychological, and biological underpinnings of sex isn’t one.

Headlines to consider:

Many people don’t know that much about sex.
Many of my clients tend toward overcontrol/inhibition and may have felt that “good” or “normal” people don’t do fun things in bed.  Both men and women may have been shamed for having sexual desires, taught to think that interest in sex is shallow or anti-intellectual.  I will admit, I once had a brooding artist boyfriend in my early 20s say he always thought sex was “sad” before me.  On the contrary, sex is a prime place for adults to be playful and imaginative, states of mind that can be hard to access for grownups — which makes it all the more satisfying when we do have great sex and all the more difficult at times to get there.

Even people who have had lots of partners may have only scratched the surface with sex — often it takes a longer-term relationship to facilitate wider exploration.  Men might be relying on the same old move that melted their high school girlfriend’s face off and feel confused when it doesn’t do much for you.  Women may not realize it can take extra time to orgasm with a new partner and be unnecessarily discouraged.

If any of this resonates with you, I recommend starting with sex therapist Ian Kerner’s books, such as Passionista for women and She Comes First for men.  Or for a quick overview of sex topics, try the Swiss nonprofit Lilli — https://www.lilli.ch/en/sexuality_understand.  Their vision is that “when [people] have sexual problems, they…invest in overcoming the limitations of their sexual learning process.”  What an empowering growth mindset to have about sex!  Think of it as a skill you can learn, like anything else — survival skills, organizational skills, social skills, sexual skills.

Spontaneous vs. responsive desire
A game-changer is knowing the difference between spontaneous desire (thinking of or being reminded of sex and spontaneously feeling turned on and ready/desire precedes action) vs. responsive desire (you start foreplay or sexual acts and then feel in the mood/action precedes desire).  Some people are simply wired for responsive desire.  Others may have felt spontaneous desire in the honeymoon phase of a relationship (approximately 18 months to three years) but over time desire can shift toward responsive.  This is particularly true of women in long-term monogamy.  Don’t misinterpret this to mean that you are uninterested in sex altogether.  The process may simply need to evolve.

When, where, and how matters.
Sexologist Emily Nagasaki’s book Come As You Are includes a great exercise for helping identify the contexts that can make or break sex.  For my clients, feel free to ask me about it in session, or pick up the book for help identifying the internal and external factors that help you, personally, have a good time.  From setting, to partner characteristics, life circumstances, mood, body image, worry about sexual functioning — getting in touch with what shows up, especially at this moment in life, can make a big difference in enhancing satisfaction.

It can be hard to talk about sex, but it’s harder to go your whole life missing out on good sex.
Don’t feel bad if it’s awkward.  Therapists are professionally trained and ethically bound to tolerate awkwardness.  And I’m sure you come by that reticence honestly, meaning there are so many reasons we can feel weird about discussing sex.  We were not all raised in sex-positive environments.  Religious trauma, sexism, exploitative porn, porn abuse, lots of stuff can be confusing and boner-killing.  Take a step toward reclaiming your birthright of physical and emotional pleasure.  If you need more inspiration, check out the Netflix series Sex Education for healthy depictions of frank and practical sex talk.  Or just do what Esther Perel does and say “erotic” instead of “sexual.”  You too will sound effortlessly sophisticated on the topic instead of faintly embarrassed and intimidated. ;)

The pros and cons skill is one of my favorites from DBT because of its practicality and versatility.  When clients are struggling with a decision -- anything from whether to leave a job to end a relationship to drink alcohol -- I enthusiastically screen-share my virtual whiteboard and create a four-square grid for us to fill in.  The benefit of this format is that it's comprehensive -- you see gaps and add details that you may not consider if simply freestyling out loud.  It is also incredibly validating, because we see in black and white how complex many decisions are, how there are significant consequences in every direction rather than one clear, "right" answer.  (No wonder we're struggling.)  Despite the complexity, having things spelled out has a tendency to nudge us forward.  We glimpse that ultimately, we're going to pick a square and live with the consequences, because even "not" choosing is a choice -- it's choosing inaction/"no"... which has consequences. 

Many of my clients identify as highly sensitive, many have social anxiety, and some identify as being autistic and/or ADHDers.  In all of these cases, eye contact, also commonly referred to as two-way gaze in scientific research, can be a bit much at times, whether in therapy or elsewhere.  Here are a few fun facts and insidious myths about eye contact.

Fact: The same part of our brain that processes language, processes eye contact.
Actually, eye contact activates many, many structures in the “social brain.”  So as long as you’re looking at someone, some of your attention/processing power is devoted to that and less available to process language, i.e. listen and talk coherently.  Perhaps this is partly why Freud had his patients stare at the ceiling, prone on a couch, rather than upright, face-to-face.  (That being said, for most therapy clients today, sustained absence of eye contact with a provider feels lacking). Researchers have also shown that performance on visual-spatial tasks is decreased when you're simultaneously tracking eye contact.  So give yourself permission to look away now and again, in therapy or elsewhere -- it may allow you to think straighter.

Fact: Most mammals generally interpret direct direct gaze as threatening.
This is why your cat relaxes when you slow-blink rather than stare at him and why your dog avoids your eyes after she shit the rug.  Even in other human cultures eye contact may be interpreted as impolite (as it frequently is in many East Asian societies).  However in the U.S. today, the stereotype is that only a "look 'em straight in the eye"-style gaze commands respect.  Be on the lookout for other types who enjoy less direct gaze — they exist!  But also recognize that some contexts require more eye contact to make your point.  And even when looking away there are options.  The excellent Assertiveness Workbook (Paterson, 2000) suggests sometimes looking up rather than down when you do avert your eyes because it reads as more “confident.”

Fact: For people with social anxiety, time slows down during eye contact — it feels longer to them than it really is (sure did for me, up to my 30s).  This is fun when you’re getting lost in your lover’s eyes and less fun when you’re blanking out staring at your boss during a presentation.  Also, participants with social anxiety show a wider gaze cone, i.e., they are more likely to perceive averted gazes as being directed at them.  For highly sensitive people with greater-than-average threat sensitivity, this is quite the recipe for awkwardness (insert meme/gif here).  Social anxiety treatment often involves education about these biases in an effort to correct them, for example, dimming the “spotlight effect,” or proposing that perhaps your friend’s blank expression isn’t about you but rather he is trying to hold in a fart.

Myth: People who avoid eye contact are antisocial.
When you’re sensitive, a little goes a long way.  Just the opening strains of the national anthem at a spring-evening high school baseball game will choke me up a little.  Same for eye contact.  It’s not that I don’t like it, it’s that… a little goes a long way, in part because I love people so much.  The effect is especially pronounced in new situations -- when I'm meeting a new person, the influx of novel stimuli to process mean my brain wants to look away at times in order to limit the tide of information.  Later in the relationship with the same person, eye contact is no biggie. 

Although currently there isn’t any actual HSP-specific eye contact research, there is some about people with social anxiety or autism (while even those authors acknowledge it’s impossible to completely disentangle SAD and ASD).  With social anxiety disorder, the hypothesis is vigilance-avoidance: that is, SAD folks pay more attention to and avoid eye contact more than neurotypical folks, because they are on the lookout for signs of negative evaluation.  With autism, there is little consensus on the intention of gaze avoidance — whether it is in fact aversion or indifference.  I recall watching footage from a study long ago that showed an autistic person looking at architectural details during the climactic scene of Who’s Afraid of Virginia Woolf rather than Elizabeth Taylor’s face.  That behavior could signify a lack of interest in the film's social-emotional content OR interest along with a desire to titrate its masterful intensity.

Myth: People who avoid eye contact have a disorder.
Firstly, we all occasionally avoid eye contact (as with the Save The Kids/Animals/World person outside Whole Foods).  Secondly, mental diagnoses are codified in the Diagnostic and Statistical Manual, in line with a medical model.  The DSM is an important part of securing funding for research and insurance coverage for treatment.  Beyond that, the medical model has serious limitations and flaws.  The DSM itself a living document currently in its sixth revision, so who knows what the future holds.  The neurodiversity movement is a reaction to the medical model that aims to destigmatize differences such as eye contact preference that aren't inherent functional limitations.  To paraphrase HSP researcher Elaine Aron, it's not inherently difficult to be highly sensitive; it's that the world was built to suit the non-HSP majority.   

Myth: We know a lot about how the brain processes eye contact/gaze/eye position.
Hahaha.  We know as much about the brain as about outer space.  We don’t even fully know why EMDR and Brainspotting, two research-backed trauma treatment modalities that hinge on gaze, work.  Surely new and even better treatments will emerge as we further explore the mysterious interplay between client and therapist eye contact: the safe, holding gaze that the social brain requires as well as the relief we all occasionally crave in order to access other states of mind.

If you’re like most people, you are curious what other folks talk about during their one near-hour of undivided attention per week, either because you’ve never been to therapy, or because you wonder if you’re “doing it right” or missing out on anything.  Many of my clients are talking about anxiety and/or depression.  Behold a sampling of greatest hits beyond/underlying that:

1. Sex.  Just kidding, people don’t talk about this unless asked.  A lot.  Not across the board; I do have clients who were raised more sex-positively, are very extraverted, and/or are therapy veterans who have come to trust that therapy really is a place to talk about anything (and they will talk about sex until they’re blue in the face :).  But otherwise, it’s something that many folks fear to broach, especially those who feel awkward about or intimidated by unmet sexual desires, both women and men.  I see a fair number of clients who are experiencing libido or performance issues in part because of years of repression and internalized shame.  People can be understandably reticent to unearth these things, but those who do often experience life-changing shifts.  If your therapist isn’t comfortable talking about sex, find one who is, or get a referral to a certified sex therapist for specific concerns while you continue to see your primary clinician.

2. Money.  Again, kidding; despite its primacy in our lives, this is also often a no unless asked.  Which can be particularly tricky if there is a significant real or perceived difference in SES between client and therapist.  Research suggests that similarity of SES is a strong factor impacting the success of the therapy relationship.  People don’t want to feel that their clinician has too much or too little money to relate to them.  But since we know money is funny and can fuck with our heads, it’s vitally important to introduce it into the mental health conversation.  And remember, therapists are professionally trained and ethically obligated to withstand awkward moments in pursuit of therapeutic gains!  (And nothing ventured, nothing gained.)

3. Relationships.  Clients spend more therapy minutes on relationships than anything else.  Even people who are exceptionally career-oriented want space to explore talking about loving and being loved.  (Rarely, this comes about only through pressure; their fed-up spouses, children, etc. demand that they pay attention, or else.)  Clients who are single by choice may talk about friendships, siblings (for most of us, the single longest relationship of our lives), or how to navigate the changing role of parents as we age.  People discuss loved ones and pets who are deceased as well.  As my very wise former supervisor Richard Dunn, LMFT once told me, “Death ends a life, not a relationship.”

Since I see many folks in their 30s and 40s, how to make friends in adulthood is also a hot topic.  What may have been a  passive process when we lived in the dorms and/or relied on super-social coworkers to just invite us out should eventually become an intentional, active, reciprocal practice (especially if you WFH!).  Knowing how to pick and make and be a good friend supports agency and healthy self-esteem as well as making for more satisfying and durable friendships.

4. Self.  The relationship to oneself, identity, self-esteem, the narrative we create around the events of our lives… All therapy gold.  And the exploration of self can be as vulnerable, analytical, irreverent, abstract, nonlinear, impressionistic, spiritual, religious, secular, profane, and pragmatic as desired.  In general I’m a more present-focused, practically-oriented therapist, but that doesn’t mean it isn’t sometimes highly practical to talk about our earliest memories, or the first time we remember being embarrassed to receive a compliment, or our confusion around the concepts of “self” and “Self” in Buddhism, for example.  This is prime mystery-of-life, I-think-therefore-I-am introspection material — so let’s go there, the more emotionally charged, the better.  I promise it will eventually relate to something current and real-world.

5. Values clarification.  People usually don’t announce, “Hey Rebecca, today I’d like to work on values clarification.”  Often the need presents as ambivalence around priorities: should I be more ambitious in my career or less, expect more from my romantic partner or less, be more flexible as a parent or less?  While a therapist will never tell you what to do and who to be (if they do, run), therapy can help weigh the pros and cons of various choices.  Often this is happening for the very first time with my clients in their 20s, but for some late bloomers, it’s new beyond that.  Otherwise, transitions throughout the lifespan make it worthwhile to revisit values and priorities as often as necessary: marriage, moving, aging, births, deaths, career change, major illness, pandemic, elections… many changes can catalyze a rethink that makes life fit and feel better.

6. Goal-setting.  Once we clarify values, we set goals based on them, either informally or formally (as in SMART goals).  On a concrete level, people generally want to swipe, scroll, drink, and emotionally eat less and exercise, meditate, read, and spend quality face-to-face time with loved ones more.  But we can’t do it all (maybe not technically true — I think I was doing “it all” for like five seconds once?).  So often it takes deep looks at what we’re actually willing to sacrifice in order to sustain change, and radical acceptance that not everything can be highest priority.  On a more subtle level, we may develop goals around how to be the kind of partner, friend, or parent we want to be, how to talk to people who have different points of view, or how to behave ethically in a world in climate crisis…  If it’s on your mind, we can break things down and identify opportunities for growth.

Other common therapy topics include body image, agita around birthdays/holidays/family visits, compulsive behaviors like overspending, porn misuse, and lying, sexual orientation questioning, and trauma, including bullying and neglect.

What do you wish you’d brought up in therapy but haven’t yet?  Answer in the comments below for a chance to... be one step closer to actually getting your needs met and your money's worth. :)