There is still a lot of mystery around sex therapy even though in recent years it has been somewhat destigmatized. However, when, where and why an individual might seek sex therapy is sometimes not clear.

Dr. Laura C. Liguori is a clinical psychologist and certified sex therapist and she provides insight on the fascinating but sometimes misunderstood subject of sex therapy.

Currently, Liguori has a private practice at Associated Mental Health Consultants in Wauwatosa and spends two days per month at the Women's Incontinence and Sexual Health (WISH) Program at Froedtert Hospital. She is also an assistant clinical professor at the Medical College of Wisconsin.

Liguori became an American Association of Sexuality Counselors, Educators and Therapists (AASCET)-certified sex therapist 2011 and since then, has helped many individuals and couples overcome a myriad of issues.

OnMilwaukee.com sat down with Liguori and asked her about common sexual problems, what kinds of "homework" she assigns to her clients and her thoughts on Dr. Ruth and Dr. Phil.

OnMilwaukee.com: What exactly is sex therapy?

Laura Liguori: Sex therapy involves individual, couple or a combination of psychotherapy. If a couple seeks therapy, I will see them initially as a couple and then as individuals once or twice and then ongoing as a couple. I do a detailed psychosexual history on each individual. This gives me a great background and also helps me begin to form a conceptualization regarding their issues. The patients and I then agree on therapy goals.

I tend to see patients every other week, and I assign homework assignments to be completed between sessions, since both the work of and benefits from any psychotherapy extend well beyond the session itself. In other words, if the patient is willing to work on issues between sessions, much more will be accomplished much faster.

OMC: What does the homework involve?

LL: Homework involving physical contact with oneself or a partner, of course, must be done in private and between sessions. Based upon the goals set by the patient(s) and myself, homework may include reading chapters from a book, using specific tools to examine one's early teachings and current ideas surrounding sex, going on dates and engaging in various levels of physical touch. Communication exercises are often role-played in session and guidelines provided for between sessions.

OMC: What are signs that a couple or a person might need sex therapy?

LL: Within a couple, if communication regarding sex is lacking or if attempts at communication have been unsuccessful, that is a huge red flag. If one is considering leaving the relationship or is considering having affairs because of sexual dissatisfaction within the relationship, that is also an indicator. Significantly differing expectations regarding sex or different preferences regarding sex – such as frequency, duration, activities – might warrant therapy as well.

Also, if one individual in a couple is experiencing sexual difficulty such as low libido, pelvic pain, erectile dysfunction (ED) or premature ejaculation (PE), they could both be helped clinically.

On an individual level, discomfort with sex due to feelings that it is repulsive, dirty or wrong would be a great thing to address in sex therapy. Or simply the issues described above such as low libido or PE would benefit from sex therapy despite one being single.

OMC: Do more women than men seek sex therapy?

LL: Women and couples tend to seek sex therapy more often than men do. Men alone might comprise one-third of my sex therapy caseload.

It's hard to separate women and couples out, because when a woman comes in, usually her partner eventually enters therapy with her, often due to the nature of the sexual problem.

Women tend to say they have low libido – or no libido. This can be related to perimenopause or menopause, either due to hysterectomy or natural aging or general hormone imbalance. It can also be attributable to factors such as life stress, a relationship issue or an issue involving childhood teachings.

Many medications also contribute to low libido in males and females. I also see women who have pelvic pain, or pain with intercourse. This is typically related to a medical problem but can also be caused by psychological factors such as difficulty with a relationship, anticipatory anxiety and having sex despite not wanting it. Body image is also a significant issue for many women and some men. This can affect libido and other sexual function as well.

I am seeing more and more women with a problem called Persistent Genital Arousal Disorder (PGAD), which is characterized by a feeling of arousal that may diminish following orgasm but returns very quickly. The arousal part sounds great compared to low libido, but this disorder can be tormenting and debilitating, as the feeling of arousal is often intense, orgasms may be spontaneous and painful and no amount of sexual activity resolves the arousal.

In addition, the feeling of arousal is absolutely not subjectively sexual. In fact, many women with PGAD avoid sexual activity. It just happens to exist in the genitals and has been compared to restless legs, but in the genitals—sort of restless genitals.

OMC: What is the most common reason couples enter sex therapy?

LL: It is usually due to lack of sex in the relationship, many times related to a woman suffering from low libido or pelvic pain. Despite the stereotype, there are also many men who suffer low libido for a variety of reasons, which may also lead to couples therapy. It is rare to do "pure" sex therapy with a couple, because there are often many communication and other relationship issues to address first. After those are addressed, sex therapy itself can be a focus.

OMC: What about male clients?

LL: Male clients most typically come in with either ED or PE. Many times ED is due to medical problems that are varied. These can be anything from prostate cancer to diabetes-related neuropathy. More rarely, a man might suffer ED as a result of fear of impregnating a woman or relationship problems. Acute stress or chronic low-grade stress can reduce libido and/or contribute to ED, as well as early teachings regarding sex. PE is most often due to psychological problems but can be exacerbated by medical issues such as problems with nerves.

OMC: The film "The Sessions" features Helen Hunt playing a sex surrogate. Apparently, this is also legal in California. What are your thoughts on this?

LL: There is absolutely no surrogacy involved in sex therapy. Surrogacy involves sexual observation and / or participation, and that is never, ever a part of sex therapy or any therapy. I wouldn't even know where to tell people to go for this if they asked.

OMC: Is sex absolutely crucial to a healthy love relationship?

LL: Yes, healthy sexuality is crucial for good human development and functioning, and it is also crucial for couples to have. It is imperative to make sure that each of the individuals feels comfortable with their own sexuality.

Within a couple, sex becomes a larger issue the more dysfunctional it is, and often each part of the couple disagrees upon factors such as frequency, duration and specific activities. Sex therapy helps to clarify many things of this nature. Because good sex requires good communication, it is often helpful for the couple in many ways.

OMC: Does a person have to be in a relationship to seek sex therapy?

LL: No, absolutely not.

OMC: Do you see people with non-sexual disorders?

LL: Yes, I also see individuals with mood disorders, anxiety disorders, issues with infertility, general life-stressors, individuals with psychological distress related to medical problems and relationship issues. I also specialize working with individuals or couples who are gay, lesbian and bisexual.

OMC: How old are your clients?

LL: I see people ages 16 and above. I see all ages, from late teens to early seventies, with 30 to 60 being the most typical.

OMC: Have many of your clients been sexually abused?

LL: Sexual abuse will be inquired about, but it does not have to be the focus if it isn't relevant to the current issue. That can be the patient's choice many times. For example, if a person was abused early in life or raped during college and the current issue is low libido, the therapist will decide whether the earlier experiences are impacting the current problem.

If not, the therapist may offer to address the abuse, and if the patient does not want to touch it, that's OK. If abuse is definitely part of the problem, the therapist will let the patient know and they will decide on treatment options from there. Not all, or even many, sexual problems stem from sexual abuse.

OMC: Are you open to all different types of couples?

LL: Yes, absolutely. Patients should know that sex therapists tend to be friendly to all sexual orientations.

OMC: How much does it cost / is it covered by insurance?

LL: Most insurances are accepted; if a clinician isn't in network, clients should check their out of network coverage. Also, most clinicians use a self-pay rate or sliding fee scale if insurance isn't an option.

OMC: What are your thoughts on Dr. Ruth Westheimer? Was she helpful in popularizing / de-stigmatizing sex therapy?

LL: Dr. Ruth is amazing. She really did and does normalize sexual problems and made it seem more OK to talk about them. She is a pioneer and has a complex and extensive educational and career history. She is a psychologist who earned her doctorate in family psychology and then studied with prominent sex therapists, so she has a comprehensive view of sexual issues. Yes, she absolutely has had a role de-stigmatizing both sexual dysfunction and sex therapy.

OMC: Is sex therapy less stigmatized than it was in decades past?

LL: Yes, I believe it is becoming less stigmatized. There are surprisingly few certified sex therapists nationally and internationally, however the number is growing. There are also surprisingly few female sexual medicine programs in the state and the U.S., though those are growing as well.

Many people feel embarrassed about it initially and are hesitant to seek treatment, even of a medical nature. Once they are in treatment or once the issue really becomes a problem that is life-interfering, they are more comfortable seeking or being in treatment. If the therapist is straight-forward and conveys comfort discussing the issues, the patient will also be more comfortable.

Also, commercials addressing ED have been helpful to men who might not otherwise seek help. Ads for over-the-counter female aids have also been helpful. I am not endorsing any products in particular.

OMC: What if someone is a private person or embarrasses easy? What would you say to them to assure that sex therapy doesn't have to be awkward? Or is it awkward sometimes and that's just part of it?

LL: As a sex therapist, I like to ask patients in the first session how embarrassed or awkward they are feeling. I also ask them what their expectations are regarding therapy and myself as the therapist. For example, I am not going to be like Dr. Phil.

Patients so often do not know what to expect, especially if they have never been in therapy. I try to really validate any discomfort and insert humor where appropriate. I also use their language, which implies comfort on my part talking about it.

Essentially, if the therapist is comfortable, that helps tremendously. It also helps to reassure the patient that any embarrassment they are feeling is entirely normal and will fade with time. Finally, I tend to let the patient know that it is very difficult to shock or surprise me, which is true of sex therapists in general.