Welcome to Doing It, a column where sex educator Dr. Varuna Srinivasan explores the deep connections between sex and emotions. This month, Dr. Srinivasan and other sexual health experts discuss the most common types of sex anxiety.
Our feelings around sex are not just complex, but unique to each person. It feels safe to say that everyone (including me) at some point has experienced a degree of anxiety about sex. For the most part, these anxious feelings are nothing to worry about. One-off thoughts like “did I forget to bring a condom,” “how do I tell them that I’m dying to do anal” or “will they notice my areolas are really brown?” are totally normal. (That last areola-related concern is a very real anxiety I have expressed to my husband.)
But for some people, these thoughts types of thoughts can be on-going and, in turn, become debilitating. Persistent, repetitive, intrusive thoughts about a specific aspect of sex can prevent a lot of people from having sex or performing the way they want to. The effects of this type of anxiety could range from avoidance to sadness to performance issues such as erectile dysfunction and arousal disorders.
These feelings are broadly referred to as sex anxiety. And while it sounds clinical, “sex anxiety” isn’t really a diagnosis a health care professional hands out during a session. Instead, anxieties around sex are often symptoms of sexual dysfunction or broader mental health conditions like anxiety, depression, or OCD. In an effort to understand more about the different types of sex anxiety and how one can deal with them, I spoke to a few of my fellow sexual health experts who offered their insights.
- Jordan Rullo, Ph.D, a clinical health psychologist and certified sex therapist based in Utah
- Stefani Goerlich, Ph.D, a clinical social worker and co-host of the podcast Securing Sexuality
- Casey Tanner, an AASECT-certified sex therapist, author of Feel It All: A Therapist's Guide to Reimagining Your Relationship with Sex, and creator of @queersextherapy
- What is sex anxiety?
- Sexual performance anxiety
- Post-coital dysphoria
- Sexual aversion disorder
- How to overcome sex anxiety
What is sex anxiety?
Sexual anxiety is really an umbrella term that includes everything from sexual disappointments (which we all face) to clinically diagnosable sexual dysfunction, according to psychologist Jordan Rullo, PhD. She notes that this type of anxiety is only diagnosed as a dysfunction when the issues last six months or longer during at least 75% of sexual experiences. At this point, one would likely benefit from meeting with a sex therapist or sexual medicine specialist.
Anxiety generally shows up in our body as a range of symptoms: chest tightness, headaches, sweating, GI distress, and more. When it’s related to sex, it anxiety can show up as avoidance and issues around performance. It can be a nasty cycle, wherein your anxiety affects your sex life and not being able to have sex the way you want makes your anxiety worse.
Clinical social worker Stefani Goerlich, Ph.D, reminds us that anxiety can feel different to different people. For some, it feels like a strong sense of fear, a low pervasive feeling of dread, or intrusive negative thoughts such as “I’m worthless,” “no one would want someone like me,” or “if I say yes to sex, something terrible will happen.”
Sexual performance anxiety
Sexual performance anxiety occurs when a person is conscious about their body, actions, or approach to sex. This type of anxiety often has a direct effect on our body, causing issues like difficulty achieving or maintaining an erection and issues around arousal or having an orgasm.
Sex therapist Casey Tanner breaks down the thoughts associated with performance anxiety into four buckets.
- Body image: “How does my body look when I’m in this position?”
- Body function: “Am I taking too long to orgasm?”
- Expression: “Are my sounds too loud?”
- Skill level: “Is it obvious I have no idea what I’m doing?”
It’s absolutely normal to have an off day, whether it’s with someone new or a long-term partner. Plus, many of our ideas around what “perfect sex” looks like comes from mainstream porn. While porn, let's be honest, was the first introduction to sex education for many of us, it often sets many unrealistic expectations around our bodies, sexual activities, and pleasure.
These issues become clinical when they occur consistently and repeatedly, even with different partners. Performance anxiety is known to cause sexual dysfunction and be associated with erectile dysfunction, orgasmic disorders, arousal disorders, and even pain during intercourse.
Post-coital dysphoria
Dysphoria is a type of anxiety where the person can feel disconnected and detached from their body. This can show up as gender dysphoria where one feels like their current body does not match their gender identity. Sex or any type of sexual activity can also be a hot bed for dysmorphia, Tanner mentions.
There is another type of dysphoria called post-coital dysphoria, which clinical psychologists categorize as a female functional disorder, where the person experiences negative emotions characterized by crying, sense of melancholy, anxiety, agitation, or aggression after sex. While it is mainly reported in women, there have been some rare cases of men experiencing it as well.
Dr. Rullo says this phenomenon is caused by both physiological responses, resulting from the “come down” of all the juicy neurotransmitters that flow during intimacy, and emotional ones, which can result from a decreased sense of excitement and closeness when sex is over.
Sexual aversion disorder
Sexual aversion disorder, or SAD, was once categorized as a sexual desire disorder in the fourth edition of the DSM (Diagnostic and Statistical Manual of Disorders, a manual classifying and defining mental disorders) and defined as a “persistent or recurrent extreme aversion to, and avoidance of, all or almost all, genital sexual contact with a sexual partner.”
Psychiatrists speculated that SAD overlaps with vaginismus, sexual desire disorder and phobias but it was eventually removed from the fifth edition of the DSM due to lack of evidence and extremely rare cases of diagnoses. These days, it's rare to receive SAD as a diagnosis. “In my opinion it is a highly stigmatizing label, because it pathologized two very normal things: libido differences and asexuality or demisexuality,” Dr. Goerlich says. “'Sexual Aversion Disorder' assumes that sexual desire is normal and that the absence of desire is problematic.”
While it may not be its own clinical diagnosis, avoidance around sex is real and can be attributed to trauma or negative associations with sex as a result of cultural, religious or societal conditioning. Having treated many patients with similar symptoms, Dr. Rullo mentions that these intense aversions around sex can also be attributable to a phobia. If that's the case, patients may benefit from a type of exposure therapy called sensate focus, which is a series of increasingly more sensual, and then sexual, exercises with one’s partner in their home.
How to overcome sex anxiety
To repeat myself: It is normal to experience moments of anxiety around sex. As a society, we are slowly beginning to understand the link between mental health and its effect on our sexual health. “Given that anxiety about sex is a natural response to tons of oppressive messaging about sex, sexuality, and relationships, I rarely think about sexual anxiety as pathological,” says Tanner. In other words, the issue is likely not just the act of sex, but rather our thoughts and feelings about it. In most cases, we’re unconsciously projecting those feelings whenever we engage in sexual activities.
The most important thing one can do is work to separate their sense of self from their anxieties and symptoms. It’s hard for us to not attribute these issues to ourselves and feel like our bodies are broken when, in reality, there are countless the things around us that affect and condition our beliefs around sex. Exploring this on your own or, if it’s accessible to you, with a professional such as a sex therapist, can provide insight into your triggers, which can ultimately help identify the underlying issue.
And this is key to overcoming sex anxiety. Regardless of which type of sex anxiety you’re dealing with, Dr. Rullo explains that the treatment is dependent on the underlying issue. “If it’s sexual trauma, then [a therapist should] help the patient process their trauma and teach them sexual communication skills,” she says. “If it’s sexual pain, then it's a referral to a sexual medicine physician and pelvic physical therapist. If it’s a history of negative messages about sex, then it's psychoeducation about sex and challenging/reframing these old messages.”
If you are in a partnership, communicating your anxieties, preferences, and needs around sex is vital to the longevity of the relationship. I know that this isn’t exactly a skill many of were taught in any type of setting but having the support of a partner can be life changing. And if you're the partner in this case, the most validating and reassuring thing you can do is not take any of these concerns personally. Reminding your partner that you still love them and want to work on these issues together can give them just the strength they need to work past their anxieties.
Read more from Doing It:
How I Deal With Having Low Libido
