Keywords

Midwives are privileged to prevent and detect sexual health problems, concerns, and doubts. In some cases, a referral can seem necessary when they lack the knowledge and skills to tackle the client’s issues.

The midwife can detect sexual concerns by listening to the woman and the couple. In that way, she can encounter sexual problems, e.g. existing before pregnancy, triggered or worsened by pregnancy, or childbirth. Furthermore, due to her close contact with the woman and her partner, the midwife may even be elected as a trusted person to share experiences of sexual abuse, neglect, and violence.

Because midwives also contact women who are willing or keen to be involved in clinical interventions to improve their sexual health or eliminate their sexual problems, we will address some basic knowledge on sex therapy. Our goal is to offer information on what sex therapy is about, enabling midwives to refer their clients to sex therapists - whenever that appears needed - with an adequate explanation of what the woman or couple can expect.

Sex therapy was initially developed as a therapeutic approach mainly aimed at changing behaviours and eliminating sexual problems. Currently, it is an integrative therapeutic intervention, utilising different therapeutic methods and tools, aimed at individuals and couples who wish to restore or improve their sexual health and well-being. Sex therapy follows a collaborative model, and people are actively involved in the process. The intervention begins with a clinical evaluation, then therapeutic goals are set together with the client(s), and finally, a personalised intervention plan is made. Sex therapists usually are psychologists, psychotherapists, or physicians of different specialities who theoretically and practically have been trained in sex therapy. Still, there are other types of health care professionals (HCPs), such as midwives, nurses, physician assistants, and pelvic physiotherapists who, with proper additional training in sexology, can provide support in some cases of sex therapy. These professionals eligible to pursue specialised training may differ across countries, so we recommend consulting the professional sexology associations in each country of interest for more accurate information.

1 Context

For several decades, professionals have discussed what constitutes good sexual functioning and a healthy sex life. Clinical psychologists, psychiatrists, and other medical specialists classify sexual dysfunctions in the DSM 5 and the ICD manuals from a clinical perspective. The group of sexual dysfunctions includes a variety of disorders, most of them characterised by sexual distress related to sexual functioning or by problems feeling pleasure. (For a brief overview of when sex isn’t working, see Chap. 3. For an overview of the categorisation of sexual dysfunctions according to DSM 5 [1]).

Sexual dysfunction can cause personal and interpersonal distress and can be related to poorer overall well-being, relationship conflict, and lower quality of life. However, one does not need to be eligible to receive a diagnosis of sexual dysfunction to experience the detrimental effects of sexual problems or to benefit from sex therapy.

Even without intense distress, couples might strive for a better sexual life and invest in sex therapy. Midwives are in the privileged position to normalise both the change in sexual experiences during the pregnancy and young parenthood and the need to seek help to promote sexual well-being and prevent sexual dissatisfaction. Sexual problems and sexual difficulties throughout pregnancy can be, for example, due to lack of information, the result of ineffective sexual stimulation in the context of bodily changes or body image concerns throughout pregnancy and after delivery. Referring people who experience sexual distress to a sex therapist with expertise in reproduction-related changes may be adequate as a measure to diminish discomfort but also as a measure that may prevent the development of a serious sexual problem.

2 Fundamentals of Sex Therapy

Sex therapy starts from a biopsychosocial understanding of sexuality [2]. The process of sex therapy closely resembles that of general psychotherapy, e.g. the therapeutic process tends to follow the standard steps of the first evaluation, then mutual goal setting followed by collaboratively tailoring interventions with the couple, best suited to help them reach their own goals with regards to their sexual lives. Regarding evaluating sexual problems, the biopsychosocial approach to sexual dysfunctions and problems allows us to understand how physical, psychological, and social variables interact and intricately determine, maintain, and eventually worsen sexual difficulties and dysfunctions. This approach enables a comprehensive assessment of medical, sexual, and psychosocial factors, and their history is considered in both diagnosis and clinical management. So when in sex therapy, the client or couple should expect a proper assessment (with sometimes more than one professional, e.g., gynaecologist and sexologist) to ensure that the relevant physical, psychological, and social factors will be carefully evaluated.

Next to the form of the process, as in all psychotherapeutic approaches, the quality of the therapeutic relationship is a determinant for the success of this type of intervention. An empathic relationship, the validation of concerns and difficulties, motivation, and positive reinforcement, is essential for the success of sex therapy.

Sex therapy is characterised by its focus on a solid therapeutic alliance, multidisciplinary in the stages of evaluation and treatment and prescription of homework assignments designed with the collaboration of patients.

Case Example: Christine

Christine is a heterosexual 40-year-old married primigravid woman pregnant for 7 months. She feels more sexual than ever but feels awkward about these feelings, although she notices her partner is enthusiastic about her renewed interest in sex. Christine thinks she is not normal and that this intense interest in sex is bad. Christine also noticed that reaching orgasm has become much easier for her. Her orgasms are, on the one hand, very pleasurable. But she feels physically depleted afterwards, causing problems because she often orgasms very soon, leaving her unsatisfied partner behind. Christine worries that he will become frustrated by how sex is going and might lose interest. She fears that her sexual interest may diminish after childbirth, causing her partner to feel disappointed. Christine is afraid she will never be as before again, and she has talked with her midwife about her worries.

3 Evaluation

Within sex therapy, the first sessions are decisive for establishing a collaborative therapeutic alliance, a clear view of the client’s desired outcomes, and possible strategies to achieve those goals. Next to establishing a good working alliance, the first sessions are characterised by the therapist trying to evaluate the client’s current situation. Looking at predisposing factors (e.g., poor sex education; negative expectations); precipitating factors related to the events that triggered the onset of the sexual problem (e.g., pain during penetration); and perpetuating factors that maintain the condition (e.g., depression and loss of desire, non-pleasurable sexual activity).

Christine’s Case

It would be beneficial to explore Christine’s expectations about sexuality during pregnancy, namely the last trimester, and her expectations about postpartum sexuality.

The following questions could be helpful:

“How did you expect your sexual desire to evolve throughout pregnancy?”

“What did you expect to happen in the last trimester and after childbirth?”

“Why would this be a problem in your case?”

The therapist should also evaluate potential triggers for Christine’s concerns:

“Did you read about this topic anywhere and did that impact your feelings on the matter?”

“Did your partner express a loss of desire, or did he notice a rise in your desire?”

“Since you started to feel your stronger desire, did you change your behaviour (e.g. checking your partner’s level of desire, reading testimonies on the internet about women’s desire during pregnancy)?”

“Do you perceive that your partner will be disappointed if your levels of desire diminish after childbirth?”

“How do you feel about the fact that your orgasm comes so quickly?”

“Did you speak to your partner about how this might affect your sex life as a couple?”

In general, the sex therapist will also assess the client’s expectations regarding the treatment, the motivation to change the current situation and the belief in the attainability of the set goals. These are considered essential elements for the patient’s involvement and the success of the intervention. For example, couples who experience sexual desire discrepancy may expect that sex therapy will ‘fix’ the person with low desire. Sexual desire discrepancy is, however, a common characteristic of amorous relationships. One cannot avoid changes in desire, and there is no objective standard for the amount of sexual desire of men and women [3].

Christine’s Case

It would be important to find out if there is a discrepancy in sexual desire and who is distressed about this: Christine, her partner, or both.

The clinical/sexual interview is an indispensable tool at this stage of the process. The therapist should collect as much information as possible about the nature and development of the problem and factors contributing to its onset and maintenance to establish a differential diagnosis while strengthening the HCP–client relationship. Evaluation in this context could assess different spheres of the individual’s life, such as interpersonal aspects (romantic and sexual relationships, family, and friendships), habits and routines, passage through the various stages of life from childhood (e.g., attitudes of parents and significant adults towards sexuality) and adolescence (e.g., sex education and first experiences) to the present (e.g., religious beliefs, sexual practices, attitudes and sexual beliefs), but only when the clinician or the patient deem them relevant. Interpersonal factors (e.g., relational satisfaction, sexual communication) can play a significant role in sexual outcomes (such as sexual satisfaction, pleasure, or distress), and, therefore, in the case of a romantic relationship, the therapist will also try to involve the partner [4]. The therapist will gather information about the current relationship, both partners’ ideas on the problem and any information they consider important.

Christine’s Case

Questions in this exploration phase could be:

“What messages gave your families, culture, and religion about sexuality in pregnancy?”

How did both internalise those messages?

How has the couple been dealing with Christine’s distress?

“Did you show your distress, or are you afraid to tell or show that to your partner?

How has the couple dealt with problems (illness, employment, family of origin) before?

(Previous challenges can indicate strengths and weaknesses relevant to the current situation.)

What are the expectations and fears about her strong sexual desire and her partner’s enjoyment? What ideas does that generate?

What changes does Christine expect about motherhood, job, partner roles, et cetera and how that could influence sexuality?

The therapist should always check previous clinical follow-ups, any physical or mental illness, and if the person takes medication. A mental health problem (e.g., depression), a physical condition (e.g., candidiasis), or medication (e.g., hormonal contraception) can be the explanation for the sexual symptoms and signals. Success may come from other interventions rather than just sex therapy in these cases.

Midwives who refer clients to sex therapy can play a crucial role by explaining that sex therapy is not a miracle therapy. Its focus is on sexual response and the emotional experiences linked to sexual activity. But it is not fast and narrowly focused on genital response and deals with knowledge of personal development.

When an organic cause is expected, a medical consultation is needed for a correct diagnosis [5]. In sum, midwives can frame expectations of women experiencing sexual problems by clarifying that the evaluation process in sex therapy uses a comprehensive biopsychosocial approach that takes a developmental look at sexual problems and assumes a multidisciplinary treatment perspective. People can expect that sharing concerns and the therapist’s act of collecting information might have a profound positive effect and lead to insight, promoting an atmosphere of trust and even modelling an atmosphere for better sexual communication.

4 Treatment

Sex therapy aims to ease anxieties, minimise difficulties, normalise experiences, and look for ways to maximise sexual health and well-being, considering the patient’s socio-cultural background and desired sexual outcomes. Over time, sex therapy evolved from a primarily behavioural-oriented approach to an integrative approach that deals with assessment and treatment through a biopsychosocial perspective [6]. Therefore, interventions can also be undertaken in a multidisciplinary clinical context.

Sex therapy is often used as an umbrella concept to refer to many possible effective interventions. Therapeutic interventions are adapted to the needs and uniqueness of the patient and, when in a relationship, to the dynamics in their relationship.

So the midwife can explain that sex therapy deals with increasing good couple communication, broadening their perspective on intimacy and sexuality, and improving how they will experience having sex.

Midwives can explain to their clients that searching for scientifically grounded information in magazines, books, or online can be valuable for couples struggling with sexual worries or problems, especially when sex therapy might not be an option because sex therapists are not available or are too expensive.

Sex therapy will almost always include an amount of behavioural therapy. One’s sexuality is expressed through feelings, attitudes, thoughts, and behaviours (alone or in a relational context). So, part of sex therapy often will focus on breaking behavioural patterns and establishing new, more functional, and satisfying ones. When needed, the sharing of information, discussion, and clarification of doubts about aspects of sexual anatomy and physiology often constitute the first sessions of the therapeutic process. Psychoeducation about sexuality is an essential tool in overcoming not-effective sexual concepts and myths that are often at the root and the maintenance of sexual difficulties. Such psychoeducational interventions can be done in individual therapy, couple counselling, or group settings [7]. The partner should preferably be part of this education. Partners tend to share inadequate beliefs and expectations about sexuality.

Through cognitive restructuring, the therapist can address more realistic beliefs. For example, regarding Christine’s idea that it is abnormal to feel extra sexual while pregnant, the therapist may address this idea an try to uncover where it comes from, how rigid and how reliable it is.

The most common sexual pitfall is the widespread idea that penile-vaginal intercourse is the only correct way to have sex or the only way for a woman to experience pleasure or orgasm. Such beliefs can keep couples focused on penetrative sex, even during postpartum pain or menopausal lack of lubrication. Such situations need education. For instance, on the clitoris and its function, sexual response changes throughout pregnancy or the physical and sexual effects of menopausal hormonal changes. Part of that education is challenging the couple to think in alternative directions. Such ‘cognitive restructuring’ may help create room for more sexual variety and experimenting, leading to more pleasurable sexual experiences free from the penile-vaginal penetration pressure.

Christine’s Case

The therapist needs to address the beliefs of Christine and her partner about what sexual changes they can expect during pregnancy and postpartum. The therapist will also normalise their solo and their couple experiences (‘That can happen!’) and call attention to their ongoing rediscovering of sexuality in new ways.

Some midwives will be sufficiently trained to provide couples such ‘Limited Information’, as in the PLISSIT model, eliminating the need for referral to a sex therapist (or in preparation before referral). For more information on the PLISSIT model, see Chap. 3.

Throughout the sessions, the therapist can indicate new experiences or behavioural patterns to experience at home in between sessions to facilitate change in the currently faltering sexual dynamic. Therapists must ensure that couples clearly understand how to go about these new experiences at home, which sometimes requires detailed behavioural descriptions of intimate or sexual activities. The more the therapist and the couple co-construct these new experiences, the greater the couple’s motivation to try them in between sessions and overcome any possible practical and emotional pitfalls when trying out new and sometimes challenging experiences. At the beginning of each consecutive session, the therapist invites the couple to share, in a detailed manner, how they have gone about trying these new experiences so that they can discuss the difficulties and gains to help promote change.

During the consultation, these experiences can be integrated into cognitive tasks (e.g., recording the automatic negative thoughts that appeared during the homework exercises) to work on them. Most people have rigid, repetitive, and limited sexual skills, with interactions generally oriented towards performance and the achievement of specific goals (e.g., reaching orgasm through penile-vaginal intercourse). Such performance-focused attention keeps patients away from concentrating and enjoying pleasurable sensations. In the opposite direction, while experimenting with new ways of sexual interaction, the therapist might advise the couple, when in a sexual encounter, to be aware of the physical sensations without desperately looking for erection, orgasm, or pleasure and, as such, rediscover the wonders of physical intimacy. Therefore, improving the sexual communication skills among partners is another relevant treatment strategy. With better sexual communication, it usually becomes easier to accept differences in desire and preferred sexual scripts by which there will be less reason for tension and guilt.

Those are all aspects of a behavioural approach, focusing on breaking down dysfunctional sexual habits and re-establishing new ones. Besides, therapy sometimes integrates muscle relaxation techniques to enhance levels of relaxation and comfort during homework exercises and new experiences. Occasionally, attention is paid to the surrounding where the homework exercises occur. A comfortable environment can facilitate the gradual development of better sexual interaction through positive associations.

Christine’s Case

For Christine and her partner, this could include addressing their habitual way of having sex and challenging their ideas and expectations concerning ‘good sex’ to create a more flexible set of sexual beliefs, expectations, and practices. In concrete terms, this could mean experimenting with new forms of sexual stimulation that might still be pleasurable to Christine but not bring her to orgasm so quickly.

Christine and her partner could benefit from attention for their feelings. When they can learn to communicate about their fears and anxieties, express themselves positively, and avoid shame and guilt, their sexual relationship will benefit.

Lastly, overcoming uncertainty could be an essential therapeutical goal, as the couple seems to feel distressed about unexpected positive experiences and seems to be distressed by the uncertainty of future events they cannot control.

The idea that women in heterosexual couples are less receptive and hesitant about sex is an example of an almost inevitable message in many sexual scripts. That idea can condition the behaviour of some women and men because women tend to expect the male partner to start sexual interaction. Over time, this internalised message becomes interpersonal, is again and again repeated, and can end up as a pattern in the relationship.

Sex therapy can identify dominant sexual scripts and how they shape and condition the exploration of intimacy and pleasure. That can create room for questioning, co-construction, and exploration of new, different scripts. In the case of Christine and her partner, sexual scripts about what normal sexuality during pregnancy and postpartum should be, may interfere with the enjoyment of the current situation and create negative expectations towards the future. In sex therapy, it is important to address these scripts and clarify that everyone can re-construct new scripts that are not based on dominant representations of sexuality.

The therapist may promote flexible sexual scripts and encourage and stimulate sexual narratives and imagery, exercises for directed masturbation and body exploration, and exercises for reducing performance anxiety and muscle relaxation. Some of these exercises are similar to techniques used in preparation for childbirth, aiming to reconnect the woman with positive body sensations. Relaxation and recognition of body responses and sensations are often used to manage sexual pain, especially when it is associated with a tense pelvic floor (for more details, see Chap. 10).

It is common for clients to have difficulties when they try new experiences at home, that have been co-constructed in the session. This can reflect other difficulties not caused by the sexual problem itself. Personal and interpersonal situations (e.g., fear they might make a bad situation worse, fear of leaving their comfort zone) can obstruct the therapeutic process, sometimes asking for extra consultation.

There is no ideal duration and number of sessions; this aspect is always fluid and continuously adjusted according to the needs and development of each client or couple. It is important to note that there is no physical contact between the therapist and the patient. All co-constructed new experiences are tried out by the client or couple in the privacy of their own home.

As an important final note, we would like to stress that most studies on therapeutic interventions have been done in common, monogamous, heterosexual, non-disabled people. So there is room for broadening knowledge on therapeutic interventions with these client groups [6].

Recently sex therapy has become even more multidisciplinary and has integrated different therapeutic approaches and strategies (e.g., systems therapy, mindfulness), establishing itself as an integrative approach to sexual problems. Also, in recent years the use of internet-delivered sexual interventions has gone up, which may translate into the inclusion of new possibilities for sex therapy, such as reaching people who have more difficulties in enrolling in a face-to-face intervention either due to lack of local resources, or inhibition about approaching sexual issues in a clinical setting.

Midwives can play a pivotal role in referring clients to sex therapy, by educating them about the why and how of sex therapy, explaining that, in the case of a couple, both partners will participate and informing them about the biopsychosocial approach. Besides, midwives should indicate that sex therapy has a more comprehensive focus than only genital stimulation and often includes homework assignmentsFootnote 1.