Ask a Sex Therapist

Your most pressing questions about sex in all its mystery, answered

Ana Maria Caicedo // Arts & Culture Editor 

On a scale of 1 to 10, how would you rate your sex life? Do you feel at home in your own body and sexuality, or could things be better?

This past decade, intersectional feminism has propelled typically marginalized discussions into the periphery of public consciousness, challenging the way many of us navigate our world and interactions. And yet, mainstream discussions of sex today still seem to start and end with safe sex education. We look to porn and television to show us what sex is supposed to look, feel, and be like. Inevitably, it’s hard to feel like you belong in our sexual climate. 

For this Valentine’s issue, the Courier asked Terri-Lynn MacKay, a clinical psychologist at the West Coast Centre For Sex Therapy, to help us demystify sex. 

AC: How do you help couples with varying sex drives find compromise?

TM: I think it’s really about understanding that sexuality comes on a spectrum for everybody. 

You might like or dislike things a lot more or less than your partner in other areas as well, and you learn to navigate those things within the context of your relationship. We tend to think of sexuality as so different, but really, it’s a lot about compromises in a relationship. 

We do tend to think a person with a higher level of desire is right, or should have their sexual needs met because we tend to devalue the idea that someone might not be as sort-of sexually fueled within our societal context. 

But every person, based on their temperament, their genetics—a whole range of variables—will have different levels of sexual desire, of kinds of fantasy arousal that we help people navigate in the context of their relationship. 

AC: In your practice, have you noticed problems that are more common for women to experience? Have you noticed problems that are more common for men to experience? If so, what are they?

TM: Women are more likely to experience physiological pain conditions, I think just because of the physiological differences between [cis] men and [cis] women. [Cis] men are much more likely to present with erectile and ejaculatory difficulties. 

But you know, in thinking about this question, one thing I’ve definitely learned as a sex therapist is men and women are much more alike than different. I mean, we all want healthy and satisfying sex lives, we all experience anxiety around sexuality, we all experience insecurities, we all want to feel valued, loved, respected and desired. 

AC: Is it harder for women to orgasm than it is for men? 

TM: Women are more likely to experience challenges with orgasm, that is true, but I would say that the main factor that contributes to orgasm difficulty for women during coupled sex is a lack of knowledge and focus on clitoral stimulation. 

There’s a really good book called Becoming Cliterate [by Laurie Mintz], and in that book she talks about the fact that only four percent of women would say that penetrative sex in and of itself is the most reliable road to orgasm, and that anywhere from 89 to 99 percent of women use no form of insertion when they masturbate. 

Yet the default sexual act is penetrative sex, often with no focus on clitoral stimulation. I talk to my clients about that and tell them that, and it makes them feel really good in normalizing the fact that their experiences are common. 

I would also say that women are more complex in their sexual response. The historic model of sexual arousal for both men and women was based on [sexuality researchers] Masters and Johnson, where there were four different stages of [sexual response]: excitement, plateau, orgasm, resolution. 

But the newer model of female sexuality, based on [the research of psychiatrist] Rosemary Basson, looks at female sexuality as being more responsive than spontaneous. So female sexuality is based on a range of factors such as motivation, willingness, context, arousal, psychological factors, relationship factors, emotional and physical satisfaction. Not to say that a range of factors don’t also influence male sexuality, but testosterone plays a larger role for men than women.

AC: It sounds almost like clitoral stimulation isn’t a part of what people generally have in mind when they think of sex, or it’s not a requirement. Why do you think that clitoral stimulation isn’t a part of the normalized definition or go-to thing when we think of sex, or I guess specifically, heterosexual sex?

TM: I mean, within lesbian relationships, people are more likely to have orgasms than they are in heterosexual relationships. In terms of the question of why it’s not front and center, I think that’s just in large part due to a historical context of female sexuality not being valued. 

It wasn’t that long ago where female orgasm wasn’t even thought to be a real thing. Female sexuality has only really become front and center to sexuality in the past 20 years. And so, it’s going to take a while to catch up, because a lot of what you see in portrayals of sexuality, particularly in pornography—not that there’s anything negative about pornography—but you don’t see a lot of focus on female sexuality and clitoral stimulation within a standard pornographic theme. 

AC: I was wondering how you’ve seen sexual culture and it’s narratives around what sex and sexy is supposed to act, look, and feel like represented in your own practice in terms of the clients who come to see you? 

TM: Well, I think the standard narrative for men is that you’re supposed to be able to get and maintain an erection and you’re supposed to be able to orgasm within a certain period of time. And if those things aren’t functioning exactly as is then there’s something emasculating about it, that you’re not a real man if those things can’t happen —as opposed to seeing men as textured and humanistic sexual beings. 

And for women as well, I think there’s a lot of narratives around sexuality. That’s why a lot of women fake orgasm, because they have the idea—and it’s portrayed in a lot of ways—that you’re supposed to be able to orgasm through fast and furious penetrative sex, which is not the case. 

AC: Are there any other common misconceptions or preconceived notions about sex that you can think of that tend to hinder our sex lives

TM: Without knocking penetrative sex too much, I do think that’s the most common misconception. Particularly for cisgender, heterosexually-oriented couples, is that penetrative sex is the primary and exclusive marker for a sexual experience. 

Sexuality can encompass such a range of experiences that are sensual and playful and connecting and stimulating and arousing and silly and erotic and engaging without putting a penis in a vagina. Non-heterosexual and non-binary couples tend to do much better in this regard. 

AC: I know this is a bit of a fraught question, but do you think there’s a relationship between being comfortable in your own gender identity and having a satisfying sex life? How can someone’s notions of gender roles influence their sex life? 

TM: Well, I don’t think that qualifier applies exclusively to gender identity. Because any discomfort in your sense of self—including gender identity and sexual orientation, body image is a really common one, feeling uncomfortable with how you smell or taste or sound or are perceived—is going to lower your ability to be in the moment and experience sexual pleasure. 

It sounds like I’m dodging the question, but it’s not specific to gender identity. There’s a lot of different ways of being or not being with yourself that hinder a sexual experience. We know being women how much pressure is put on women to look and be perceived in certain ways, so there are a lot of women as well that come with different body image concerns. 

A lot of what we see in sex therapy is anxiety-related. It’s related to not being able to be vulnerable and being afraid of how you would be perceived. Just not feeling comfortable in your own skin makes it really difficult to enjoy a sexual experience. 

AC: Do you think hook-up culture impacts the value given to intimacy?

TM: I certainly think that there’s benefits and drawbacks. I think some of the benefits are that it does value female sexuality in the sense that there’s not as much of the slut-shaming that used to occur, and women being able to have the right and opportunity to go out and seek out sexual experiences in and of themselves can be really liberating. 

But on the other hand, when you have more choices it can be really challenging to stick with the choice you have. My grandma grew up in a community where there were seven people, and you chose from those seven people. Whereas now, where you have a whole litany of options with things like Tinder or Grindr, it really does, I think, contribute to the mentality of “I’m going to find something better if I just keep looking,” which does impede someone’s investment in intimacy. 

AC: Have you ever worked with someone with trauma from a previous sexual assault that hinders their current sex life? 

TM: When someone experiences a trauma, or even when someone feels a really high level of stress in their life, there’s a sympathetic nervous system response that can actually make it even physiologically difficult for the body to relax. 

So we work with people to sort of calm the neurophysiological response away from fight or flight, because if you’ve had a traumatic sexual experience your body’s going to very quickly go into a fight or flight response. 

That can include collaborating with other disciplines—there’s some people here in Vancouver even who are somatic sex educators—to help people feel more at ease in their body. There’s elements of that that look at some of the cognitive aspects of what someone’s thinking, some of the emotional aspects, mindfulness—so being able to be really present in your body at the time that something has happened as opposed to disassociating from that experience. The major challenge of that for the client is that it’s really scary to be vulnerable and present in your body when you’ve been hurt or violated. 

AC: What kind of advice would you give to someone who feels inexperienced in sex or hasn’t had sex in a long time to improve their comfort and self-confidence?

TM: There are a number of really good books on sexuality that can be quite helpful. There’s a new book called Come As You Are [by Emily Nagoski]; it’s a wonderful book on female sexuality that’s very comprehensive. For men, there’s a book called The New Male Sexuality [by Bernie Zilbergeld]. I taught human sexuality at UBC, and quite frankly there’s a real dearth of information about sexuality and some of the physiological aspects of how your body works and the complexity of sexuality, so [those books are] a good place to start. 

And then again, to move away from the goal of penetrative sex being the end all and the be all. Because that goal creates a lot of anxiety and excludes a whole repertoire of experiences that can be connecting and sexually satisfying. 

AC: What advice would you give to couples in long-term relationships that are feeling bored or unsatisfied with their sex life?

TM: At the beginning of a relationship, sexuality is very spontaneous. It’s very exciting, everything’s new, everything’s novel, and over time that changes. 

There’s a sex and relationship therapist, her name is Esther Perel, and she talks about basically these two aspects of relationships that are juxtaposed to each other. On one side of that you have the desire for stability and security and for nesting, and on the other side of things you want spontaneity, you want excitement and you want novelty, and one kind of squishes the other. 

And so, what I often talk to couples about is to create space for things like connection, idleness, and playfulness. Not scheduled sex, but scheduled time for being playful or sensual or intellectually stimulated or silly or excited, which are states that are very close on the spectrum to sexuality. 

These are things that people really prioritize at the beginning of relationships—like having showers together and giggling and dancing or whatever people do—that fall off the map as time goes on. You know, most couples get very busy with the tasks of daily living and expect that sex will continue to be spontaneous in a long-term relationship, and it’s just not. Nor is it particularly fun to feel you have to have sex at a specific time. But what is fun is creating more ways to be in a space of being, what I would consider, connected to the vitality of life, where you’d be more likely to have sex. 

*This interview has been edited for brevity and clarity

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