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Finding a Therapist | Sexual Addictions | Sex Therapy
Transgender | Disability | Asking a Question

Finding a Therapist

Q What is the difference between a psychologist and a psychiatrist?

A psychiatrist has attended medical school and completed a residency in psychiatry. A psychologist, on the other hand, has usually completed 4 years of graduate school and an internship in psychology. Although both are experts in emotional and behavioral issues, they approach problems from different viewpoints. The psychiatrist, being a medical doctor, often sees emotional difficulties from a physiological perspective and typically prescribes medications for problems such as depression and anxiety. The psychologist, as a behavioral scientist, understands the problem from an emotional/family background and uses approaches such as therapy, counseling or hypnosis. For certain problems, the two individuals may work together using both counseling and medications.

Q How do I find a counselor or therapist to work with?

Word of mouth or a referral from a friend are often the best places to start. If you have an HMO or insurance that will pay for therapy, you can obtain a list of therapists who are covered under your plan. Other ways to find a therapist include calling a local hospital or mental health center, contacting your state psychological association, using the yellow pages or the internet. Be a cautious consumer! Ask about credentials, experience, specialties and professional activities. If you feel uncomfortable with the therapist, continue looking elsewhere until you find someone that you feel comfortable with.

Q How do I find a sex therapist?

Some psychologists and other therapists may specialize in sex therapy or couples counseling. Sex therapists in the United States are credentialed by The American Association of Sex Educators, Counselors and Therapists, (AASECT). This association provides a referral service by calling 1 (804) 644-3288 or by connecting to their web site at You might also get information and a referral from your primary care doctor, urologist or gynecologist.

Q How do I know where is the best place to get help?

Often, finding the right professional for you or a partner is a trial and error process. As a rule of thumb, consider finding a professional who is “plugged” into a larger network. A professional who works in isolation from other colleagues can ultimately be a disadvantage for the patient. Today, sexual concerns are often seen as multi-faceted and require an expertise beyond that of a single individual. For example, before undergoing extensive sex therapy, insist on a medical evaluation. At other times, even though there may be a medical problem, don’t neglect attending to your relationship. Insist on getting the best help possible and don’t settle for second best!

Q Is there a charge for the first consultation with a psychologist or therapist?

Most often psychologists and other mental health professionals do charge for the initial meeting. There are exceptions to this practice in different countries, different states and among various practitioners. If money is a concern, ask about this courtesy when calling to set up the first appointment. A clinical practice is a small business however, and economics usually dictate that it is necessary to charge for professional time.

Q How do I know that information discussed with my therapist will be kept confidential?

There are very strict laws in all states that regulate what information can be released to other people or to insurance companies and attorneys. In general, a signed release of information is necessary before any information can be shared with other people. The exceptions to this law include the reported abuse of a minor or when there is sufficient concern about the safety of the patient or another person. Your state psychological association can provide you with specific information for your state. It is always recommended to discuss this issue with your psychologist at the beginning of treatment.


Sexual Addictions

Q Do sexual addictions really exist?

Yes, sexual addictions do exist and can create chaos in the lives of an individual and their family. Moreover, sexual addictions can also put the individual in danger of legal action, potential violence or sexually transmitted disease. Whether specific behaviors can be considered sexual addictions may vary from person to person. However, an addiction may exist if an individual is unable to control certain sexual behaviors; the sexual behavior is self-destructive and it interferes with the normal daily functioning of the individual.

Q What type of sexual addictions are seen by psychologists?

There is a tremendous range of sexual addictions that people experience and seek treatment for. Over the last several years, addictions to internet pornography are very common. This type of addiction may be accompanied by excessive masturbation lasting long periods of time or by the use of prostitution. Other forms of sexual addiction may involve exhibitionism, public masturbation, uncontrolled sexual contact with strangers and a wide variation of activity designed to elicit sexual pleasure.

Q What types of treatments are available for a person with a sexual addiction?

There is no one form of treatment that has been proven most effective. Often, a combination of treatments are used in working with the person who has a sexual addiction. For example, some of the psychiatric medications can be helpful in reducing sexual drive or in decreasing sexually intrusive thoughts. These medications may also allow an individual to consider consequences before acting on a sexual urge or impulse. In addition to medications, treatment almost always involves therapy or counseling on a regular basis. In the United States there are also self-help programs for people with sexual addictions. These are modeled after the AA 12 step programs and are found in most major cities in the US.

Q What can I do if I think my partner has a sexual addiction?

Clearly, the first step is to speak with your partner and discuss your observations and concerns. Like all addictions, denial is common. In some cases, the individual may not realize that a problem exist or that certain behaviors have become out of control. Encouraging psychological treatment and providing strong emotional support are critical if changes are expected. Expressing emotional support is often difficult at this time because of personal distress and feelings of anger.

Q How can someone I love do this to our relationship?

In trying to grasp a situation such as this, it is important to remember that the sexual behavior is an addiction. Like all addictions, they serve a purpose. Often, the behavior is an attempt to cope with feelings such as depression, stress or other emotionally painful material. In other cases, there may be a void in the individual’s life or in their primary relationship. Typically, the reasons behind addictive behavior are complex and multi-faceted. For this reason, marital or couple’s counseling may be an adjunct to treatment

Q Can a sexual addiction really be eliminated?

Like any addiction, maintaining control and avoiding future problems is a difficult, life long process. Maintaining sobriety over sexual addictions requires strong motivation and a constant vigilance over times of potential danger. With good emotional support however, it is possible to make the necessary changes. For most people, a sense of over-confidence and a premature termination of psychological treatment and support are the biggest mistakes that can lead to future problems.


Sex Therapy

Q How do I know if my sexual difficulty is from a psychological or physical problem?

The answer to this question may depend on whom you ask. A mental health professional may believe that your problem comes from a psychological issue and a medical doctor may feel that there are physical concerns. The reality is that most sexual difficulties have both psychological and physical components that can contribute to the problem. Today, because of recent medical advances, physical causes are often discovered in the majority of cases. The psychological or emotional component thus may be a result of the sexual problem rather than causing the sexual difficulty. Also, relationship issues often emerge after any form of sexual difficulty. Because there is no simple answer to this question, a good sex therapist should refer you to a medical doctor for an evaluation while a medical doctor may also suggest that you address the emotional issues with a therapist.

Q If my sexual difficulty is because of psychological causes what can I do?

There are new effective treatments for people who have sexual problems due to either physical or psychological reasons. Almost everyone who has a sexual difficulty hopes that a physical reason can be discovered. We all want a quick fix and hope that a pill can solve our problem. (This is why Viagra has become so popular.) Psychological causes for a problem are much more vague, difficult to understand and sometimes more difficult to treat. If there are psychological difficulties, we tend to blame ourselves and self-esteem is affected. Unfortunately, even in this age, many people feel a sense of shame and inadequacy about psychological problems. We all believe we should be able to fix the problem ourselves without seeing a professional!

Q Shouldn’t I wait to see if a sexual problem goes away on its own before I see a professional?

With sex being such a personal matter, most people do wait considerable time before seeking professional assistance. The embarrassment surrounding sexual difficulties often prevents people from getting early help. Some problems do clear up on their own especially if they are related to factors such as excessive alcohol consumption or stress. However, if a problem persist over a period of weeks or months there is a good chance that the situation will not improve without some professional intervention. Once a sexual problem has occurred, even once, we tend to anticipate difficulties every time in the future. This loss of sexual confidence and fear of failure can easily intensify an already existing sexual difficulty.

Q I am unable to ejaculate during intercourse although I have no difficulty during masturbation. What should I do?

This problem is often seen in clinics and can be either from medical or psychological issues. For example, a decrease in the sensitivity of the penis may be caused by a nerve injury thus making ejaculation difficult with the friction of intercourse. On the other hand, anxiety about reaching orgasm may be another factor. A good medical evaluation is an essential first step and would be recommended by most therapists.

Q What causes pre-mature ejaculation?

No one is quite sure how men develop problems with rapid ejaculation. However, many professionals believe that the ability to control one’s ejaculation is a skill that is learned during adolescence and early adulthood. Often, masturbation is considered a method in which this response is learned and mastered. Although the problem is more common among young men it can persist throughout the life span of an individual. Today, in addition to the standard sex therapy treatments available, medications (such as anti-depressant medications) are often used to delay ejaculation. Unfortunately, some of these medications can also have a negative effect on sexual interest and the quality of a erection.

Q Is it common for women to loose interest in sex after the birth of a child?

Men and women may lose interest in sex at any time throughout their lives. Often, this lack of interest may extend for years. For women, the loss of sexual desire after the birth of a child is very common and is poorly understood. Newer research is beginning to suggest that a decrease in hormone levels may play a major factor in this condition. In spite of its frequency, good treatment is also difficult to find. Most ob/gyn doctors have little to suggest that will improve sexual desire. Naturally, such a situation can create extreme tension in a marriage and often leads to frustration, anger and marital conflict. Some Urology departments at major medical centers are beginning to take an interest in this condition and offer treatment to the woman and her partner.

Q Is it normal for sexual intercourse to be painful for women?

Female sexual dysfunction is a new area of scientific study and at this time little is known about its causes. It is not normal for women to experience discomfort during sexual activity or intercourse. However, there can be numerous reasons why intercourse may be painful for women and it is a common complaint. Physical reasons may include low androgen levels, lack of arousal and lubrication or internal structures such as cysts on the walls of the vagina. Doctors are just beginning to understand the many variables involved in causing women to experience sexual discomfort. Psychological issues such as anxiety, past sexual trauma, rape, abuse or relationship difficulties may also be factors related to discomfort during sexual intercourse. Like many female sexual problems, evaluation and treatment for these problems may be difficult to find. As more women become vocal about sexual dysfunction however, doctors are being forced to address their concerns. It is important to be a strong advocate for yourself in seeking treatment.

Q Why do men have such a difficult time facing a sexual difficulty?

Most men will develop some form of sexual dysfunction at various times throughout life. Often, this will be a crisis in the man’s life. For many men, these difficulties are temporary and can be attributed to stress, fatigue, medical issues or a pre-occupation with work or some other aspect of their lives. Because sex is such a vulnerable area for many men, issues of masculinity often come into question when a sexual difficulty arises. Self doubt can intensify almost any sexual difficulty and feelings of inadequacy are usually very prevalent. A man’s masculinity and his sexual attraction to others are not related to the quality of erections, sexual desire or ability to delay ejaculation. Having a sexual difficulty need not be a serious, anxiety-provoking situation.

Q Isn’t it normal to have sexual problems as you get older?

Most men and women do develop some form of sexual dysfunction as they age. Often, this may be a result of some medical issue such as a circulation, hormone or neurological problem. Also life style factors such as alcohol use, smoking, weight and cholesterol levels have been associated with sexual difficulties. Even depression and many medications have sexual side effects. Nevertheless, many people stay sexually active throughout their lives and have a strong sexual desire even into their 70s and 80s. Although it may be common to develop sexual problems as you age, you should expect to be sexually active throughout life. If not, treatments are available at any age.

Q Will Viagra solve my sexual difficulties?

In spite of Viagra being the most popular medication ever developed, it will not solve all sexual problems. It was originally developed for the treatment of erectile difficulties and has been proven to be very effective in many cases. Although not intended for other problems, it is sometimes used to help with low sexual desire and ejaculation problems. Its effectiveness in these types of cases has not been proven and is often used in conjunction with sex therapy. Currently, Viagra is also being studied in the treatment of women’s sexual problems. Viagra has opened the door for research on new medications for the treatment of sexual dysfunction. If you have a sexual problem, it is wise to stay in touch with medical professionals as new oral medications and treatments are constantly being developed. We are in a time of tremendous revolution in the treatment of these problems.



Q Is there a transgender program in the Boston area?

Boston Medical Center has established itself as an important resource for the New England transgender community. This program is made up of a multidisciplinary team consisting of psychologist, endocrinologist, primary care doctors and surgeons. In addition, weekly support groups, conducted by members of the community, are held at the medical center.. A number of people also receive psychological or medical services at this facility while obtaining additional services at other facilities in Boston or throughout the country. Other services are available at local health centers, community agencies or through individual private practices.

Q Will insurance pay for a sex change?

Most insurance plans generally do not pay for the psychological and medical expenses relating to a sex change. Unfortunately, these services are not considered medically necessary by most states or by the insurance industry. Moreover, the expenses can be considerable given the cost of psychological treatment, hormones and possible surgery. Because this is typically an extended process, costs are often spread over several years and many practitioners use a sliding scale for payment of services. Every case is individual however and it is best to speak with your therapist or doctor about the financial obligations involved in this undertaking.

Q Why is psychotherapy necessary before staring hormone therapy or undergoing surgery?

In order for an endocrinologist to consider hormone therapy or for a surgeon to perform sex re-assignment surgery, the individual must meet the DSM-4 psychiatric diagnostic criteria of gender identity disorder. This is determined and documented through a psychological evaluation. The results of this evaluation are communicated via a letter to the physician prior to initiating treatment. Prior to surgery, supporting letters from two separate therapists may be required by some surgeons.

Q How long do I need to be in psychotherapy before I can start hormones?

The Standards of Care provide considerable flexibility in this area and length of psychological treatment depends on a variety of factors. These include real life experiences, age and past treatment. Although there is considerable latitude regarding therapy requirements, a few months of therapy provides a good opportunity for the therapist and patient to know each other and to identify potential difficulties. Ideally, therapy should help to facilitate a smooth adjustment to hormone treatment. This gradual process of changing genders with therapy, hormones and surgery is called transitioning. Some therapists, including myself, consider it important to stay involved throughout this process.

Q Is a sex change permanent?

The psychological services relating to sex re-assignment are obviously designed to explore one’s options. Since beginning a treatment of hormone therapy alters body structure and mass, this should be considered permanent and done only after careful thought and discussion. Surgical changes, which are the final step in a sex re-assignment, are naturally permanent.

Q How do I get more information about transitioning?

The process of changing one’s gender or sex is called transitioning and is undergone only after very serious consideration, intensive psychotherapy and professional medical consultation. Most individuals that would consider such a process have been extremely unhappy with their biological gender since early childhood. Often, they have experienced serious emotional difficulties and profound depression. As a result of their experience, they see no option other than sex-re-assignment. It is a process that requires a commitment of many years and requires considerable emotional, financial and physical hardships. There are professional standards of treatment (The Harry Benjamin Standards) that are closely followed in most cases. Reviewing these standards ( and joining a transgender support group is a good place to start.



Q How long does it take to adjust to a disability?

Psychological adjustment to a disability is a life long process that is different for every individual. There is no correct way to adjust or normal process of adjustment. In fact, some people may never feel a sense of adjustment or acceptance. The important point is that at some time after an injury or illness, life must go on. If emotional difficulties are preventing you from living a ‘healthy functioning” life, it may be helpful to consider talking to a professional about your feelings and thoughts. Only the person with the disability and their loved ones can determine whether they have adjusted to their new situation.

Q Is it normal to be concerned about sexuality after a disability or when major medical problems have occurred?

Almost everyone has questions, anxieties and concerns about relationships and sexuality after a disability. Such concerns are completely normal. Unfortunately, it can be difficult to get information on these topics while in the hospital or after discharge. Because sexuality is such a private and personal matter, many people don’t feel comfortable in asking questions or seeking information about these areas. If you have questions at any time regarding your sexual functioning, be persistent in finding a professional who can provide you with the information you need. You have a right to be fully informed as to how your medical condition will affect your sexual expression.

Q Why wasn’t sex talked about when I was in the hospital or during any of my doctor appointments?

Medical professionals, including doctors, may feel uncomfortable talking about issues relating to sexuality. Family values, moral or religious beliefs and cultural considerations may play a factor in whether any professional will approach the topic of sex. Also, most professionals have received very little training, if any, on the topic of sexuality. Often, professionals will wait for the patient to ask the first question or to give an indication that sexuality is a concern. If your doctor does not feel comfortable with the topic, ask for a referral or seek help from someone who feels more comfortable with sexual functioning. You may need to be assertive in getting accurate information.

Q Which medical conditions can have sexual implications for me and my partner?

Virtually all serious medical conditions and disabilities can have an impact on how sexual feelings are expressed. For example, sexual changes may result from any illness that affects the genital region, breasts, pain levels, mobility, urination, bowel movements, balance, sensation, communication, mood, breathing, hearing or eyesight. If you have concerns regarding your sexual functioning always ask your doctor. Never expect that your doctor will raise these issues without your prompting.

Q What is so different about the sexuality of a person with a disability?

In reality, sexuality for people with disabilities is not so different than it is for any person. The person with a disability however has greater obstacles to overcome in becoming sexually active. These include both medical issues and cultural prejudices. Medical problems and physical disabilities often affect sexual abilities and require significant physical and psychological adjustments. Also, people in society typically regard people with a disability as non-sexual. These negative attitudes can make it difficult to meet people and to have a successful relationship.

Q. Since my spinal cord injury, I can never quite reach an orgasm. Is there anything I can do that would get me closer to an orgasm?

A. The ability to ejaculate and have an orgasm is a complex neuromuscular process that is adversely affected by a spinal cord injury. Following injury, it is not unusual for individuals to have significant difficulties in reaching orgasm. In most cases, loss of sensation and inadequate stimulation contribute to the problem. Thus increasing stimulation, especially in areas where sensation may be spared, is a worthwhile pursuit. Many individuals find that using a vibrator with adjustable amplitude can provide the level of stimulation necessary for ejaculation and orgasm. Increasing visual and auditory stimulation may also be helpful in enhancing the level of arousal. In addition, some experts believe that regular and frequent sexual activity may also increase the likelihood of restored ejaculatory functioning. Ongoing sexual activity maintains the integrity of the various chambers and arteries of the penis. Remember when using a vibrator; be especially careful of autonomic dysreflexia.

Q. Can women with complete spinal cord injuries have an orgasm?

A. Up until the last few years, there was the common belief that men and women with complete injuries were not capable of achieving a physiological orgasm. Instead, memories of the past, feelings of closeness and a sense of well-being were described as an “emotional orgasm” and were offered as a substitute to a physical orgasm. The research done by Marca Sipski, M.D. at Kessler Rehabilitation Center and at the University of Miami has clearly demonstrated otherwise. This has been ground breaking research and worth reviewing by women who see this as important. Although the physical reasons for this are still unclear, many women of all levels and with complete injuries can be orgasmic under the right conditions. Some of the factors that have been found to correlate with the ability to have an orgasm are: comfort with one’s body, persistence, knowledge about one’s sexuality and intensity of stimulation. To date, no studies have demonstrated similar results for men with spinal cord injuries.

Q. Viagra doesn’t seem to help me with my erections? What’s the next step?

A. Although studies have demonstrated that Viagra is effective with about 80% of men with spinal cord injuries, there are many individuals who continue to have difficulty achieving or sustaining an erection after such an injury. If the situation is not urgent, I would suggest speaking to your doctor about the new medication Vardenafil (LaVetra) which is scheduled for release in 2003. This medication, which did not get FDA approval in 2002 as expected, is said to be three times as strong as Viagra. In general, if oral medications are not effective, injections are the next logical step. Penile injections continue to be very effective for many men and satisfaction rates are high. Most people prefer them to using a more artificial option such as a vacuum constriction devise. Try to avoid a penile implant since these are always permanent and will make you a very poor candidate for any new treatments or medications that may be developed in the future.

Q. Does Viagra improve sexual functioning for women with spinal cord injury?

A. Research is still trying to answer this question and a multi center SCI study is currently underway. Early studies with women did show that Viagra was no better than a placebo for women who had low desire and poor lubrication. Currently, the new studies with women have been redesigned to exclude women with poor desire. Thus, in addition to the spinal cord injury studies now underway, Pfizer is exploring the impact of Viagra on women with poor lubrication who have normal desire. It is just a matter of time before oral medications to improve women’s sexual functioning make their debut. Today however, we just don’t have the answers.

Q. Does sexual functioning improve over time since injury?

A. There is no precise answer to this question although many people do report positive changes over a period of years since injury. For example, it is not unusual for some men to report having an ejaculation or an orgasm for the first time several years after injury. Other men notice gradual improvements in the quality of their erections. Being sexually active on a frequent basis may be the most helpful tool in improving your sexual functioning over time. Frequent sexual activity tends to maintain good blood flow to the genitals and contributes to the integrity of penile tissue. Many of the early studies with Viagra demonstrated the long-term benefits of frequent engorgement of the cavernosal arteries and corporal chambers. There is truth to the old saying, “use it or lose it!”

Q. So much has changed after my injury. Can guys with spinal cord injury really enjoy sex?

A. Early after injury the idea of resuming a positive sexual life can be overwhelming. Some men tend to avoid sexual activity because of embarrassment, poor self-esteem or the fear of failure. On the other hand, some men see this as a challenge to be conquered. These men learn as much as they can and take advantage of every opportunity to be intimate. Over time and with confidence about their sexual abilities, they enjoy long lasting relationships and frequent sexual intimacy. It is possible to have a great sex life after an injury but it doesn’t develop without a personal commitment to make it happen. Having an enjoyable sex life requires time, practice, and the knowledge that sex is an important part of life not to be missed.


Asking a Question

Q How can I get an answer to a personal question?

Most professionals will be pleased to provide answers to personal questions and you should never hesitate to ask questions regarding sexual concerns or other matters. If you have a question that was not answered in the above list, you are welcome to click here in order to send me a confidential e-mail.

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