I have been working in stress management and psychosexual therapy for several years and realise that that the stated problem of the client often masks an underlying problem.

I have found it increasingly useful to have knowledge and experiences of both professions. As sex is often an unasked question, I thought I would share some of my experiences with you. This is not meant to be an insult or condescending, simply helpful.

Long or short -term stress can cause problems with sex; this we know and acknowledge. Problems with sex and/or relationships can cause long or short-term stress.

Psychosexual therapists, doctors and counsellors should be aware of this as it may lead to more serious health problems.

The human body responds to sexual awareness and activities through a series of brain and body responses. The cortex of the brain controls the body functions and can be ‘switched on or off’ by the senses, memories- both conscious and subconscious, circumstances, moods or imagination.

The strongest of these is the imagination, i.e. ‘what the brain imagines is going to happen will happen’, so love making becomes a self-fulfilling prophecy. For example, if a man has had a failed erection in the past and wonders if this will happen again, then it probably will, so reinforcing his sense of failure.

Apart from a positive attitude towards sex, other aspects come into play. The brain sends neural messages down the spinal chord using both sympathetic and parasympathetic nerve pathways. If these are damaged then the response will be absent.

This nerve stimulation also causes the capillary bed around the pelvic organs to relax allowing blood to be diverted to the capillaries and become congested.

This causes the penis to become engorged and erect and the hormone influenced [excretion] lubricates the vaginal walls. It also encourages the clitoris to become enlarged by the erectile muscles and the uterus to become more upright, straightening the cervical canal allowing easier access for the sperm.

So other reasons why this does not work can be a diminished blood supply, such as with anaemia, hypertension, cardiac problems, smoking and pelvic nerve damage following surgery, and episiotomy. Medication, diabetes, ageing and alcohol also affect performance.

It is worth remembering that the urge for sex is governed by the limbic system, a primitive reactive system that ensures the continuation of the human race.

After all, if we actually stopped and thought about the act, would we logically indulge?

Sexual problems are divided into the following groups:

Low or absent desire: this is defined as an unwillingness to initiate sexual activity or a low or decreasing sex drive. In women, a previous term for this was ‘frigidity’.

Arousal problems: in women this can be seen as the normal sexual dampness of the vagina and nipple and clitoral erections being absent. In men there is absence or incomplete erection of the penis.

Penetration problems: sometimes due to physical or psychological problems in either sex.

Orgasmic problems: in men this can be an inability to ejaculate, or premature ejaculation. In women orgasmic problems may be due to technique, previous experiences, circumstances or expectations.

Miscellaneous problems: such as legal, family or parental concerns, gender, cultural or gay/lesbian issues, problems after rape or abuse, or childbirth difficulties, all may end up at the therapist.

All these problems are different and need different therapy, questioning and assistance. Sometimes more than one problem is present at the same time within a relationship.

When clients attend a therapist the most important thing is to build up a non-judgemental relationship stressing confidentiality. Taking a history of the following areas is essential as well as acknowledging the limitations of the therapist.

A personal history of the client and her/his partner to record age, job, previous relationships, children, responsibilities, interests etc.;
A medical history of the client and her/his partner to record illnesses, operations, investigations, medications and life style such as smoking, alcohol, recreational drugs.

Many treatments, for example of hypertension, arthritis and antidepressants, can be significant, as can anaemia and diabetes. If these are linked to ageing, realism must be part of the equation;

A sexual history of the client and her/his partner. This is best done on a one to one basis when the perception of the presenting problem can be discussed confidentially.

From the information gleaned the therapist can make initial decisions. It may be that the client needs to be referred to a GP or to a specialist for further investigation or treatment.

Some clients need to know more about their medication or problems to help them make decisions. Some need counselling in a safe environment to allow them to explore old or new problems.

Some need stress management and others need therapy that they can work through and report back on progress to the therapist.

There is no quick fix to sexual problems. Viagra has not become the elixir of youth that it was promised to be as the relationship and attitude problems are not touched by medication.

Some therapists work with couples and others with individuals. Some offer couple counselling with a mixed sex pair of therapists.

It is ‘horses for courses’ and the approach differs each time. In my practice I use a variety of techniques, from hypnotherapeutic approaches to brief therapy. Sometimes I teach and sometimes I support. I can be directive if appropriate and into true counselling mode at other times.

My experiences as a stress manager enable me to ask the right questions on issues surrounding the presenting problem and offer solutions that the client may try.

Sexual problems, if not addressed, do lead to stress and should not be ignored. Stress often leads initially to a lack of interest in sex, a diminishing arousal phase and sometimes performance problems.

Due to the tiredness that stress causes sex becomes the first thing to go in a relationship under stress. Couples need to be reminded that sex is a continuum from eye contact and holding hands through to penetrative sex.

Cuddles and physical contact and loving remarks still need to be indulged in and need not necessarily lead to penetration.

Some stressed individuals become clinically depressed and this aggravates low self-esteem. Post-traumatic stress disorder is often a significant cause of sexual problems and the client needs time to explore the cause if they wish to.

Other clients are unwilling to delve too deeply into the past and this wish must be respected.

Even as an experienced psychosexual therapist I know my limitations and refer the client on if the help the client requires is beyond my area of expertise.…