Denise and Edward love Mardi Gras and jazz and a dance that’s something like the electric slide. But in bed, they just couldn’t find their rhythm.

“When we were dating, sex was no problem,” says Edward (the two opted to use their middle names to preserve their privacy). “But as soon as we got married, that went out of the way; everything else was more important.”

“Everything else” includes their children, ages 10 and 4, and their careers; Denise, 40, works in a university registrar department, and Edward, 38, is a computer programmer who also manages a security company.

He wanted more sex. She wanted slower, more satisfying sex. “I’d feel a surge of something good, but by the time he climaxed, I hadn’t had a chance to climax,” Denise says. After childbirth, she experienced vaginal dryness that made intercourse excruciating. “Sometimes, after sex, I’d be crying in the dark.”

Two years ago, Edward watched a documentary that referenced author/educator Marla Renee Stewart, co-founder of the Sex Down South Conference. The couple agreed they had nothing to lose. According to Stewart, they became star pupils.

Kiss Each Other Every Day

Over the course of weekly or bimonthly Zoom sessions (Stewart is based in Atlanta, but the couple lives in Birmingham), Denise and Edward completed worksheets about everything from daily routines – who takes out the trash? who disciplines the kids? who typically initiates sex? – to what smells, sounds, and gestures they found arousing.

Stewart gave them homework: Kiss each other every day before leaving the house. Try lubricants. Experiment with sex toys. And consider how every aspect of their lives, including parenting, affects their Sexual experience.

“Sex is a symptom of what’s really happening in the relationship,” Stewart says. “There may be trust or communication issues. It is much, much broader than just the sex itself.”

Both partners say Stewart’s interventions worked. Denise learned about clitoral stimulation and tried masturbating to discover what she found pleasurable. She describes her arousal pattern as “more like an oven” – slow to heat up – while her husband is a “microwave.”

After 2 years of coaching and practice, “I’m more patient, I’m more intentional, I’m more strategic,” Edward says. “I wanted to be better at intimacy, at sex. If you really want to be good at something, you have to throw away your inhibitions and tell how you feel.”

Research has shown that nearly half of adults in the United States experience sex-related issues at some point in their lifetimes – issues that include sexual violence or trauma, questions about gender expression or sexual orientation, sexual shame, lack of libido, erectile dysfunction, or inability to reach orgasm. Some people seek Sex Therapy to help them navigate a gender transition or open a monogamous relationship to include multiple partners.

And certified sex therapists­ – who hold advanced degrees in counseling, psychology, or related fields plus additional hours of sex therapy training and clinical experience­ – have particular fields of expertise and distinct ways of working with individuals and couples. Here are five of their approaches.

Building Body Awareness

Juan Camarena, PhD, a clinical counselor, sex therapist, and executive director of the Center for Community Counseling and Engagement in San Diego, sometimes tells clients about his own experience in Catholic Mass – especially the part when parishioners thump their chests and intone, “por mi culpa” (it’s my fault). That ingrained sense of shame, which may have roots in particular cultural beliefs or practices, can impede sexual expression later on, he says.

Camarena, who describes himself as “a multicultural sex therapist,” discusses race, religion, physical ability/disability, gender and sexual orientation with clients, and he takes those aspects of identity into account when offering strategies and support.

“I’m not just trying to use interventions designed for a white couple in the 1960s,” he says. For instance, exercises that call for sustained eye contact between partners may be uncomfortable for those raised in a culture where direct eye contact is considered rude. People who are transitioning may not want certain parts of their bodies to be touched.

Camarena might recommend “mindful masturbation” as a way to build body awareness and self-love. “Prepare for masturbation the way you’d prepare for a date,” he says. “Are you groomed? Did you shower? Your job is to start from the top of your head, work your way to your feet, and find places to touch that feel good on your body.”

Whether working with couples or individuals, people in their 70s or pre-adolescents (Camarena had an 11-year-old at a camp for transgender youth ask him, “How do I know if I’m kinky or not?”), he emphasizes that there is room in the world, and in bed, for all parts of a person’s identity.

“We all have questions: Am I normal? Am I OK? My fundamental belief is that there is nothing inherently wrong with you. Our identities aren’t problems to fix; they are sources of strength and resilience.”

The Most Common Problem – and the Most Complex

Clients of Emily Jamea, who has a PhD in sexology and a private practice in Houston, might find themselves being offered a raisin during therapy. Jamea will invite them to describe the raisin – texture, smell, taste – as they sniff, chew and swallow it. Or she might ask them to graze the inside of one arm with the other hand, noticing when their thoughts wander and gently reminding them to refocus.

Such exercises in mindfulness have a connection to what’s happening – or not happening – in the bedroom, says Jamea. “The most common issue [clients present] is that one person wants to have sex more than the other” – and it’s not always the man in a heterosexual couple, she notes. “Despite the fact that it’s the most common problem, it’s also the most complex.”

A chasm in sexual desire may have its roots in longstanding resentment between partners or in sexual trauma for one or both people. “Or they may have become complacent and aren’t giving their relationship the attention it needs. They assume sex should be effortless and spontaneous like it was in the honeymoon phase.”

Mindfulness, she says, can help in stirring awake the neural pleasure-pathways and in becoming more attuned to a partner’s nonverbal cues. In addition to in-person sessions, Jamea has developed a 6-week online course focused on sexual satisfaction and “flow state” – that seamless state of mind people may experience when exercising, creating art or simply relishing a moment of being.

“People think success in sex therapy is the absence of dysfunction,” Jamea says. “But I think it’s when they are feeling a more holistically fulfilled sexuality – that it’s not just physically pleasurable, but a form of self-expression that adds meaning to their lives and enhances their relationship.”

You Can’t Just Think Your Way to Better Sex

Although she’s a talk therapist – a clinician with training in sex therapy and founder/executive director of the Center for Growth Inc./Sex Therapy in Philadelphia – Alex Caroline Robboy believes the route to great sex isn’t just in clients’ heads. Instead, she views her role as similar to that of a swim coach. “There’s a certain percentage of the work that is very technical. You can’t just think your way into having better sex.”

That’s why she’s broken down classic “sensate focused” exercises into 5-minute increments such as the “moan/groan game” – one partner gives the other a back massage, with the receiver responding nonverbally to indicate pleasure or displeasure.

Another game – “this or that?” – helps partners indicate what kind of touch they prefer. “A lot of people can’t say, ‘I like it when you stimulate my left nipple,’ but they can tell you which [form of touch] they like better. These are techniques to help people read the other person’s body language.”

Robboy works with a wide range of clients, including those in nontraditional relationships – “throuples” of three equally committed adults, or open relationships that may involve one or both partners dating or having sex with others.

“A lot of my job is to help couples understand what the unspoken rules are – what would make each of them feel jealous and what would make them feel safe? What happens if one person gets scared? What happens if one changes their mind? What if someone gets pregnant or gets an STD?

“I look at my role as not to define what’s ‘good’ or ‘bad’; it’s to help everybody have a voice and understand the risks that they are taking.”

The two-dozen-plus clinicians at the Center for Growth have areas of expertise – infertility, trauma, compulsive sexual behavior, erectile dysfunction – and work with clients of all races, genders, and orientations.

The essential goal, Robboy says, remains the same: “Can you be flexible? Can you be comfortable in your own skin? Can you be in the moment?”

Sexual Healing

Wendy Maltz, an Oregon-based sex therapist for 35 years, noted that some of her clients had a difficult time with traditional strategies – for instance, starting with mutual massage and moving incrementally toward genital touching and intercourse.

“I realized the common denominator was sexual abuse in their histories. Standard sex therapy was too much, too soon and too sexual.”

Maltz, retired now and creator of the website HealthySex, developed a series of “relearning touch” exercises, wrote The Sexual Healing Journey, and began to advise clients with histories of sexual violence or trauma to start with a hand-clapping game – one partner makes up a clapping routine and teaches it to the other – as a way of practicing eye contact and physical closeness in a non-threatening setting.

She encourages creativity and playfulness as part of healing. One client, a woman who experienced vaginismus, painful clamping at the vaginal opening, due to sexual trauma was using dilators to become more comfortable with penetration. The woman sewed a tiny tutu for the dilator and drew a face on it to make the experience feel less clinical.

“Sexual abuse is an experience where you are robbed of your power,” Maltz says. “Sex therapy has to incorporate these individual histories and not retraumatize the survivors.” She says partners, as well, need to become informed about the impact of sexual abuse. They must be patient and attuned to their partner’s triggers and emotional cues.

“Don’t pressure your partner for sex,” she advises. “Develop a team approach. Ask, ‘Would you like to be held?’ Check in a lot. Partners [of sexual trauma survivors] need to understand that they can play a powerful role in the healing.”

We’ve Been Taught to Step Outside of Ourselves

Lexx Brown-James, EdD, describes herself as a recovering Baptist, “the coolest nerd you will ever meet,” and a proponent of “shame-free sex education from womb to tomb.” She wrote The Black Girls’ Guide to Couple’s Intimacy and a children’s book, These Are My Eyes, This Is My Nose, This Is My Vulva, These Are My Toes.

Sexual shame begins in childhood, she says. When parents insist that children eat everything on their plates, or when they criticize their own bodies – “I look so fat today!” – in front of their kids, they convey messages that undermine self-worth.

“We’ve been taught to betray and step outside of ourselves,” says James, who practices in Pennsylvania and Missouri. “Sexuality becomes so veiled. It’s whispered. Lovers won’t even talk about their own sexual fantasies.”

The way to counter such self-defeating messages, which may be more intense for people of color and those who are LGBTQ, is to start early, using correct anatomical terms when talking with children and helping them to both savor pleasure and set boundaries.

“We can say: It feels good when you eat the right amount of food. It does not feel good when you say ‘no’ and Grandma comes in to kiss you anyway.”

Where gender expression and sexual orientation are concerned, James says, parents should communicate that “you get to decide who you are.” They should also be aware of their own biases. “If you’ve been raised in a trans-phobic household, religion, or culture, you might not be a safe person for your queer kid. So find community members you trust who can be.”

She encourages clients, whether older teenagers or octogenarians, to apply the same precepts to their own sexual lives. “We talk about who helped reinforce your belief systems: your church, your mom, your grandparents? We talk about what it means to navigate and negotiate boundaries in a relationship, to say: ‘You don’t have to hide these things in the dark.’”