Start with a medical visit
Sexual problems often involve both the body and the mind, but the safest first step is usually medical. Medications, blood pressure, diabetes, hormone changes, infections and pelvic conditions can all play a part, and some are easy to address once identified. MedlinePlus notes that occasional sexual problems are common, and recommends seeing a health care provider if a problem lasts more than a few months or causes distress for you or your partner.
Many doctors do not ask about sex unless you raise it. It is fine to say at the start of a visit, "I'd like to talk about a sexual health concern." Clinicians hear these questions regularly.
A map of who does what
Primary care physician
A good first stop for most concerns. A primary care doctor can review your medications, check for conditions such as diabetes or heart disease, order blood tests where appropriate, and refer you to a specialist. If the concern turns out to have a medical cause, treating it may ease much of the problem; if not, ruling things out is still useful information.
Gynecologist
For pain during sex, vaginal dryness, and changes after childbirth or around menopause. ACOG advises seeing an obstetrician-gynecologist or another health care professional for frequent or severe pain during sex, to rule out gynecologic conditions. It adds that an ob-gyn can also help with problems of sexual response, such as low desire or arousal.
Urologist
For erection and ejaculation concerns, testosterone questions, and pain or changes in the genitals or urinary tract. Cleveland Clinic advises seeing a primary care provider, gynecologist or urologist for sexual function issues first, to look for underlying physical causes.
Menopause specialist
When perimenopause or menopause is part of the picture, a clinician with menopause training can discuss options for dryness, pain and other changes. The Menopause Society offers a searchable listing of health care professionals, including those who hold its Menopause Society Certified Practitioner (MSCP) credential.
Pelvic floor physical therapist
The pelvic floor muscles support the pelvic organs and play a part in arousal and orgasm. The ISSM notes that pelvic floor physical therapy may be used for painful intercourse and vaginismus, and in men for painful or premature ejaculation, using education, exercises, hands-on therapy and other techniques. The American Physical Therapy Association's Choose PT guide lists pain during sexual activity among symptoms a physical therapist can help with, and suggests looking for a therapist with advanced training or board certification in women's health or pelvic health physical therapy.
Psychologist or other licensed therapist
For the emotional and relationship side: anxiety about sex, shame, low desire tied to stress or depression, difficulty talking with a partner, the effects of past trauma, or distance that has grown around a physical problem. Licensed psychologists, counselors, social workers and marriage and family therapists may all do this work, with different training. Dr. Lehmann's therapy for intimacy and sexual concerns sits here.
Psychiatrist
A physician who specializes in mental health and can prescribe and adjust psychiatric medications. If you take medication for depression or anxiety and suspect it is affecting desire, arousal or orgasm, the prescriber, whether a psychiatrist or a primary care doctor, is the person to raise it with. A psychologist can help with the feelings around the change but does not prescribe.
Couples therapist
When the difficulty lives mainly between partners, such as a long standoff over desire, hurt after rejection, or a breakdown in trust, some couples prefer to work on it together. Couples therapy is offered by clinicians from several professions, including psychologists.
Sex therapist
A licensed mental health professional with additional specialized training in sexual concerns. Cleveland Clinic notes that sex therapists use talk therapy and do not treat physical conditions, such as low testosterone, themselves. Sex Therapist, Couples Therapist, or Psychologist explains how the titles and credentials differ.
Putting the pieces together
These roles overlap, and you do not have to see them in strict order. The ISSM describes pelvic floor therapy as one part of a plan that may also involve primary care physicians, gynecologists or urologists, sex therapists and mental health professionals. Someone with painful sex, for example, might see a gynecologist to rule out a medical condition, a pelvic floor physical therapist for muscle tension, and a therapist for the fear and avoidance that have built up around intimacy.
It can help to think of one person as your anchor, often a primary care doctor, who keeps track of the medical side and makes referrals. Therapy can start while a medical evaluation is under way. What should not wait is the medical piece when there is pain, bleeding, a sudden change, or a question about medication. Do not stop or adjust a prescription on your own; talk with the prescriber.
Preparing for an appointment
Appointments can be short, and it is easy to freeze or forget the question you came with, especially when the subject feels awkward. A few written notes can make the visit more useful, and you can simply hand them to the clinician if saying it aloud feels hard:
- What changed, and roughly when it started
- Whether it happens every time or only sometimes
- All medications and supplements you take, including recent changes
- Other health changes, such as pregnancy, surgery, menopause symptoms or a new diagnosis
- What you would most like help with
If you suspect the cause is mostly emotional, it is still worth mentioning to your doctor. Is It Physical or Emotional? explains why the two so often go together.