Abundant Practice Podcast - Episode #634: What the Heck is Sex Therapy, feat. Erika Miley
Host: Allison Puryear
Guest: Dr. Erica Miley
Release Date: March 31, 2025
Introduction to Sex Therapy
In Episode #634 of the Abundant Practice Podcast, host Allison Puryear welcomes Dr. Erica Miley, a seasoned clinical sexologist and certified sex therapist. The episode delves into the intricacies of sex therapy, exploring its significance, common issues addressed, and the challenges therapists face when integrating sexuality into their practice.
Defining Sex Therapy
Dr. Erica Miley begins by outlining her journey in sex therapy, emphasizing the lack of comprehensive sex education in the United States compared to countries like those in the Nordics and Germany. She highlights the profound impact this deficiency has on individuals' sexual identities and mental health.
Dr. Erica Miley [01:29]: "Let's talk to all things sex. I feel excited."
She introduces the concept of sexology, her area of expertise, which examines the interconnectedness of mental health and sexuality. Dr. Miley emphasizes that sex therapists use sexuality as a lens to understand broader mental health issues, such as gender identity, desire, and the influence of religious and cultural trauma.
Dr. Miley [02:05]: "We use sex as our lens to try to understand so many other parts of our mental health and our experiences with our body."
Dimensions of Human Sexuality
Allison and Dr. Miley discuss the multifaceted nature of human sexuality, identifying key dimensions that include:
- Gender Identity: Understanding how individuals perceive and express their gender.
- Sexual Attraction: Exploring who individuals are attracted to and how it influences their relationships.
- Desire and Pleasure: Addressing how desire is experienced and the role of pleasure in sexual relationships.
- Cultural and Social Factors: Examining how societal norms and religious backgrounds impact sexual health and identity.
Dr. Miley [06:18]: "Pleasure or how do you experience pleasure sexually or non-sexually? Because a lot of times our brain will put it all together and not really understand the difference, especially if you have a trauma history."
Common Issues Addressed in Sex Therapy
Dr. Miley identifies the most common reasons clients seek sex therapy:
- Initiation Difficulties: Struggles with initiating sexual activity with partners.
- Desire Discrepancy: Mismatched levels of sexual desire between partners.
Dr. Miley [19:51]: "The most common things that we see are initiation. So initiation with any partner. And we would also see desire discrepancy."
She references Dr. Emily Nagoski's concept of desire being akin to "gas and brakes," where desire fluctuates based on various factors like stress or environmental cues.
Dr. Miley [22:57]: "Desire is like gas and brakes and they're going all the time. It's not just one or the other."
Impact of Neurodiversity and Mental Health
The conversation shifts to how neurodivergence, such as ADHD, and mental health issues like eating disorders, intersect with sexuality. Dr. Miley shares insights from her dissertation on ADHD's impact on sexual functioning, particularly in AFAB (Assigned Female at Birth) individuals.
Dr. Miley [09:02]: "Neurodivergence in particular is my wheelhouse. My entire dissertation is about ADHD and how ADHD symptoms impact AFAB people's sexual functioning."
She discusses how body shame associated with eating disorders can hinder both sexual and non-sexual pleasure, emphasizing the need for therapists to integrate sexuality into their clinical assessments.
Therapist Discomfort and Training Gaps
Allison and Dr. Miley address the prevalent discomfort among therapists when discussing sexual topics, often stemming from insufficient training. They stress the importance of integrating comprehensive sex education in graduate programs and ongoing professional development.
Dr. Miley [15:48]: "We need 25 more hours. But I think that this actually begins... in graduate school."
She advocates for supervisors to facilitate open conversations about sexuality and for therapists to seek specialized training or consultation when facing complex sexual issues in therapy.
Case Studies Highlighting Sex Therapy Challenges
To illustrate the practical applications of sex therapy, Dr. Miley presents several anonymized case studies:
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AFAB Individual with Religious Trauma:
- Background: Grew up in a toxic, patriarchal, religious household with strict gender roles.
- Issues: Deep shame around sexual desire, absence of orgasm, and struggles with sexual pleasure.
- Therapeutic Approach: Gradual reintroduction to non-sexual and then sexual pleasure, education on anatomy, and building a supportive relationship with their partner.
-
AMAB Individual with Erectile Dysfunction:
- Background: Often linked to societal pressures on men to be sexually knowledgeable and always desiring sex.
- Issues: Erectile dysfunction stemming from shame and lack of sexual education.
- Therapeutic Approach: Addressing physiological health issues, deconstructing patriarchal beliefs, and educating about sexual anatomy and desire.
Dr. Miley [25:29]: "This person is in tears because for the first time in their entire lives, they've actually met somebody that they're attracted to... we spend a lot of time doing education individually together with our partner."
Addressing Trauma and Conversion Therapy
The episode also touches on the trauma experienced by queer individuals subjected to conversion therapy. Dr. Miley emphasizes the long-term effects of such experiences on sexual identity and desire, advocating for specialized therapeutic interventions to help clients embrace their authentic selves.
Dr. Miley [42:02]: "I wish that this case study wasn't as common as it is, but it is a deeply traumatizing experience for them."
Practical Strategies for Therapists
Dr. Miley shares practical techniques used in sex therapy, such as:
- Neutrality Before Positivity: Starting with neutral activities to build a sense of safety before introducing positive sexual experiences.
- Mindfulness and Sensory Exploration: Using mindfulness to help clients reconnect with their bodies and sensations.
- Educational Exercises: Encouraging clients to familiarize themselves with anatomical terms and healthy sexual practices.
Dr. Miley [32:13]: "We start with neutrality before we offer positivity... activities that don't seem to have something tied to them is usually where we begin."
The Importance of Open Conversations About Sex
Both speakers advocate for normalizing discussions about sex both within therapeutic settings and in broader societal contexts. They highlight the protective benefits of sexual education in preventing abuse and fostering healthy sexual relationships.
Dr. Miley [48:56]: "Kids who can describe their bodies and describe their genitals and words and know about their bodies, it is protective of them."
Conclusion and Forward Look
In closing, Dr. Miley underscores the essential role of sex therapists in addressing the cultural taboos surrounding sexuality. By fostering open, informed, and empathetic conversations, therapists can help reverse the damage caused by inadequate sex education and societal stigma.
Dr. Miley [60:23]: "We are the place that you talk about the things we don't talk about in our culture. And so we need to be able to hold it all or at least have some level of comfort with it that allows it to be disclosed in a safe way for our clients."
Allison Puryear thanks Dr. Miley for her invaluable insights, reinforcing the episode's message on the critical need for comprehensive sex therapy in contemporary practice.
Key Takeaways:
- Comprehensive Sex Education: Essential from an early age to foster healthy sexual identities and prevent trauma.
- Integration in Therapy: Sexuality should be a fundamental component of mental health assessments and interventions.
- Therapist Training: Ongoing education and supervision are crucial for therapists to confidently address sexual issues.
- Cultural Sensitivity: Understanding the diverse backgrounds and experiences clients bring to their sexual health.
- Protective Education: Empowering clients with knowledge about their bodies serves as a safeguard against abuse.
This episode serves as a pivotal resource for therapists seeking to deepen their understanding of sex therapy, offering both theoretical frameworks and practical strategies to enhance their practice.