Sex Therapy from a Systemic Lens
Rebecca Brennan
National University
Dr. Kiser
MFT-8310
2/8/2026
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Sex Therapy as a Field
Sex therapy is a very important role in today’s culture. Sexual problems are more
abundant then in past generations (Belous, 2012). Approximately 31% of men and 43% of
women report sexual issues in the last twelve months (Belous, 2012). The issues reported are
lack of intimacy, sexual pain, problems becoming aroused, and inability to ejaculate (Belous,
2012). Sexual assault is on the rise and only 40% are reported (Belous, 2012). Rapes tend to
be committed 66% of the time by an someone the person knows (Belous, 2012). Many women
have encountered sexual violence, about one in four (Department of Justice, 2007).
About 8% have a pornography addiction with most people spending an average of
eleven hours on pornography sites a week (Belous, 2012). This increases the likelihood of
having an extra-marital affair, men more than women (Belous, 2012). It is imperative that
marriage and family therapists have training in sexual violence, sexual therapy, and affairs.
Timeline see appendix
Systemic Thinkers
Systemic therapists have to many times think “outside the box” to be able to work with
sexual issues for the couple. While the relationship is the most important thing, the
interventions need to be put into place to help the couple (Henderson, 2013). CBT couples
therapy is an effective tool with four elements “feedback, goal consensus, collaboration,
and positive regard” (Henderson, 2012 p.133). In essence, the client’s become
the therapist and they discover their problems through curiosity and collaboration to change
(Henderson, 2012). Systemic thinkers have adapted sexual therapy because sexual behavior is
Influenced by family systems and perceived notions (Hertlein, 2015). Sex has and always will be
effected by family values, rules, and experiences, therefore it has become a systemic issue
(Hertlein, 2015). Societal norms have changed throughout the years including what the DSM
constitutes as “normal” behavior (Hertlein, 2015). In 1973 homosexuality was taken out of the
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DSM and was no longer considered a mental health issue (Hertlein, 2015). As therapists it
is important to qualify “clinical judgement” (Hertlein, 2015). They do this by recognizing both
criteria and level of distress (Hertlein, 2015).
Similarities and Differences of Sex Therapy and Systemic Sex Therapy
Sex therapy is the understanding of sex and the dysfunction surrounding it. Sex therapy
is talk therapy with interventions regarding the sexual dysfunctions the couple is having
(Tabatabaie, 2014). The goal is for the couple to leave therapy with improved sexual
relationship functioning (Tabatabaie, 2014). However, many therapists have noted that just
“sex therapy” often times does not fully improve the couples’ sexual relationship and it negates
to find underlying problems that may exist (Tabatabaie, 2014). The primary focus with sex
therapy is to work on “confidence, pleasure, and intimacy” (Tabatabaie, 2014 p.271). A model
often used is frisky rather than foolproof (Tabatabaie, 2014). The goal is achieved when the
couple agrees that they have developed satisfaction with their sexual relationship (Tabatabaie,
2014). There are several measures to be able to test sexual function from the “Sexual
Interaction Inventory, the Derogatis Sexual Functioning Inventory, the Golombok-Rust Inventory
of Sexual Satisfaction, the Sexual Experience Scales, and the Sexual Interaction System Scale”
(Tabatabaie, 2014 p. 273). All have positive and negative results for determining the
effectiveness of sex therapy.
Systemic sexual therapy has a different lens. Sex therapy was not ever discussed in
psychotherapy until Alfred Kinsey looked at normal and abnormal sexual behavior starting in
the 1940’s and 1950’s (Wiley, 2010). Kinsey said that sexual problems can change within the
couple once the system of change is brought on through a systemic lens (Wiley, 2010).
When a therapist looks at client’s sexual problems from a systemic lens, they look at the couple
as a whole, not just their sexual problems. The therapist looks at attachment styles, interaction
with parents and how sex was talked about, genograms, intersystem domains, constructs within
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life cycles, and triangular theory of love (Hertlein, 2015). Sex therapy from a systemic lens
is much more inclusive with the dynamics of the couple and the family (Hertlein, 2015).
Examples
A sex therapist may take an evaluation of a couple and provide interventions to help
them improve their sexual intimacy such as sensate focus (Hertlein, 2015). Whereas, a
systemic sexual therapist may get a sexual history on each partner, do a genogram, and not
just look at the sexual issues, but may look at attachment styles secure, anxious, avoidant,
anxious avoidant (Hertlein, 2015). Attachment styles determine a lot for how a couple
engages with one another (Hertlein, 2015). For example, a secure person has low avoidance
and low anxiety, a person with anxious attachment style is highly anxious and has low
avoidance, a person with avoidant attachment style has high avoidance and low anxiety, and
a person with anxious avoidant has both high anxiety and high avoidance (Hertlein, 2015).
A systemic sex therapist believes that this translates to their sex life (Hertlein, 2015).
Modernist Models versus Postmodern
Modernist models might describe sex in three stages “Human sexual response cycle”
which is “excitement, plateau, orgasm, and resolution” (Hertlein, 2015 p. 17). Traditional sex
therapy was not viewed as being systemic (Hertlein, 2015). However, after an article was
published “Integrating Sex and Marital Therapy: A Clinical Guide, in 1987”, therapists began to
view the importance of assimilation of sex in couples therapy (Hertlein, 2015). Many couples
therapists began to use an integrative approach (Hertlein, 2015). MFT’s began to realize the
importance of sex relations with the couple’s intrinsic and exterior worlds (Hertlein, 2015).
The intersystem approach looks at all models biological, physiological, relationship patterns,
attachment, parental influence, culture, religion, and the like (Hertlein, 2015).
Postmodern systems may look at the intersystem approach (Hertlein, 2015). This
incorporates the idea that different territory brings on different behavior (Hertlein, 2015).
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Postmodern theorists would incorporate theories of love and interaction and attachment
(Hertlein, 2015). Interdependence is where the partners learn to trust each other to meet
their needs (Hertlein, 2015). Attributional strategy is when the partner’s conduct leads to
motivation of the behavior (Hertlein, 2015). A husband may feel that he cannot perform sex
well, therefore he ejaculates early so the act is done quickly (Hertlein, 2015). Reframing this
for the couple could be very powerful so they can both get their needs met (Hertlein, 2015).
The triangular theory of love is “commitment, intimacy, and passion” (Hertlein, 2015 p.42).
All of the three issues are vital for continuing a healthy, loving relationship long term
(Hertlein, 2015). The differences here between systemic and sex therapy is a sex therapist
will focus on affection, whereas a systemic therapist would focus more on inwardness and
engagement (Hertlein, 2015). Negative thought patterns create a negative relationship, by
focusing on positive regard and positive bids, this can help the couple develop fondness for
one another which can enhance their sex life (Hertlein, 2015).
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References
Belous, C.K. et al. (2012). Revisiting the sexual genogram. American Journal of
Family Therapy, 40(4), 281-296.
Henderson, P. (2014). In praise of “ordinary “sex therapy. Sexual & Relationship
Therapy, 29(1), 132-134.
Hertlein, K.M. et al. (2015). Systemic sex therapy. New York, NY: Routledge.
Tabatatabaie, A. (2014). “Does sex therapy work? How can we know?”
Measuring outcomes in sex therapy. Sexual & Relationship Therapy,
29(3), 269-279.
Wylie, K.R. et al. (2010). Original article: Working interactively using a systemic
sex therapy model for common sexual problems within a modern health
service setting. Sexologies, 19(4), 196-201.
U.S. Department of Justice. (2007). 2007 National Crime Victimization Survey.
Washington, D.C. Government Printing Office.
