Is the classic post-coital question “Was it good for you, too?’ ” outmoded?
A recent conference would indicate yes. Last month, the New York Center for Emotionally Focused Therapy held a symposium in New York called “Sex and Attachment: Coming Together.”
The event, with workshops on polyamory, sex-therapy interventions and compulsive sexual behavior, sold out to 400 clinicians, with a waiting list.
In March, the Psychotherapy Networker Symposium in Washington, D.C., the largest gathering of therapists in North America, offered nine workshops dealing with sexuality, sexual orientation and gender identity. Five years ago, there were only two.
In traditional couples therapy, which is about 50 years old, sex has often been shoved to the sideline. Practitioners are trained to work on underlying relationship issues, like blame or communication, many discussing sex only if the couple wants to talk about it.
But in the last decade, as coupledom itself has been legally redefined, a chorus of provocative voices in couples therapy has emerged, emphasizing the importance of good sex in relationships and sometimes suggesting the radical idea that couples fix the sex before tackling other issues.
These renegades of couples therapy — such as Suzanne Iasenza, Margie Nichols, Jean Malpas, Marty Klein, Joe Kort, Arlene Lev, Marta Meana and Tammy Nelson — have become popular speakers at conferences like “Sex and Attachment.” They speak on topics like affairs, “gender-queerness,” transsexual identity, kink, BDSM (bondage/discipline, domination/submission, sadism/masochism) and pornography to audiences more accustomed to a language of betrayal and forgiveness.
The den mother of the group is Esther Perel, 56, the internationally known, Belgian-born author of “Mating in Captivity,” who asserts that mystery and distance could benefit long-term monogamy.
Ms. Perel, based in Manhattan, is writing a book tentatively called “Affairs: Cheating in the Age of Transparency,” and gave a TED talk about the topic in March that has been viewed about two million times. Her newest provocation is the idea that trauma-based language around affairs is limiting.
“An affair is an act of betrayal and also an experience of expansion and growth,” Ms. Perel said in an interview. “It is a relational trauma, but it isn’t a crime. The family can often come out of it stronger and more resilient, and often an affair will draw the couple out of a place of deadness.”
Ms. Perel holds occasional individual sessions in which, by request, she will keep secrets from the other partner in couples work. The goal is for both partners to be honest with the therapist, if not (yet) each other. “Because we agree on this in advance,” Ms. Perel said, “if something comes out and it has to do with an affair, I am never in an ethical breach.”
Another emerging voice on infidelity is Dr. Nelson, 52, a New Haven-based couples and sex therapist and author of “The New Monogamy: Redefining Your Relationship After Infidelity.” She encourages couples to write their own monogamy rules, which can include extramarital sex on weekends or extramarital sex but only together.
“I describe monogamy as honest, perpetual dependency of some type,” Dr. Nelson said. “It can be whatever a couple wants, but it has to be fluid and flexible and the couple has to keep renewing it, like a license.”
Dr. Iasenza, 59, a psychotherapist in New York, is known for her expansive approach to gender, sexual orientation and pleasure.
She shows her clients sexual-response models like the Basson model, which contradicts the orgasm-focused, human sexual response cycle developed by Masters & Johnson (excitement, plateau, orgasm, resolution), positing that a partner can initiate sex for reasons aside from excitement, and arousal may precede desire. (This may be a mind-blowing idea for women who feel, especially after 10-plus years of marriage, that waiting for desire is like waiting for Godot.)
Dr. Iasenza also schedules private sessions with each partner, taking sexual histories and giving them homework to write sexual “menus” (lists of turn-ons), which they later share with each other.
To understand why sex-forward couples therapists may still be considered renegades in the era of shows like “Girls” and “Transparent,” it may help to know that concept of couples therapy is only slightly older than the Sexual Revolution. It was pushed to the fore in the early 1960s by Don D. Jackson, Virginia Satir and Jay Haley at the Mental Research Institute in Palo Alto, Calif., and Murray Bowen at Georgetown University Medical Center.
Sex therapy, invented by Masters & Johnson, evolved separately — and neither William Masters nor Virginia Johnson were couples therapists or mental-health providers of any kind. Today, there is only one certification program for sex therapists, the American Association of Sexuality Educators and Counselors, which means aspiring sex therapists may find access to courses and supervisers a challenge.
And though the association requires its certified sex therapists be licensed social workers or psychologists first, couples therapists are not required to have any training in sex. Ms. Perel, for example, said she received exactly one hour of education on sex in her psychotherapy training, which led her to become certified in sex therapy in 2010, more than two decades later.
Margie Nichols, 68, a psychologist and sex therapist, received zero hours of course as a clinical psychology student. She went on to found the Institute for Personal Growth in Highland Park, N.J., in 1983, then one of few mental-health centers for gays and lesbians. Today, the institute, which also has centers in Jersey City and Freehold, also counsels transgender people, but half of the clients are what Dr. Nichols calls “mainstream.”
Because her practice is diverse, she often finds herself looking to one group to help her with another. Her perspective, she said, is “G.G.G.,” which comes not from the annals of Freud but a 2006 column by the Seattle-based syndicated sex columnist Dan Savage. It means a person should strive to be good in bed, giving to the partner and game for anything — within reason.
Dr. Nichols says kinky couples have the best sex of any long-term couples she sees. Because of this, she finds herself “selling” their principles to vanilla (non-kinky) heterosexuals.
“Kinky couples plan sex,” she said, “and simmer for days in advance. They emphasize quality of encounter over frequency of encounters. They practice variety and exploration. They don’t judge a partner’s desires. They discuss and negotiate sexual acts, and they make a clear demarcation between ‘normal’ couple zone and ‘sex zone,’ allowing them to be totally immersed in an erotic space.”
One of the thornier issues affecting modern couples (kinky or not) is Internet pornography.
Marty Klein, 65, a marriage and family therapist and sex therapist in Palo Alto, questions the existence of pornography addiction and says no one has the right to a pornography-free home without consulting their mate.
“Many couples haven’t come to terms with the question, ‘Is it O.K. if my husband or wife masturbates?’ ” he said. “If you haven’t come to terms with that, or with the fact that most adults have sexual fantasies, then how can you have a productive, collaborative conversation about pornography? The country is flooded with high-quality free porn, and the problem is that people are anxious and secretive because they’re getting the message, ‘If you watch that stuff, I’ll kill you.’ ”
He takes a more tolerant approach. “I say to the couple, ‘Let’s talk seriously about how come two people who love and like each other don’t have sex any more.’ ”
Not surprisingly, Dr. Klein’s approach has detractors. Sue Johnson, 58, the developer of Emotionally Focused Therapy and clinical psychologist in Ottawa, specializing in couples, said that if pornography “takes over your life, it is going to wreck your relationship, just like any other addiction.”
As for infidelity, she said, “the idea that an affair is a solution to a lack of engagement and connection with your partner, that’s the craziest solution I’ve ever heard.”
Dr. Johnson’s program, as well as other couples therapist certification programs like Imago, emphasize safety, loyalty and attachment as the foundations of intimacy. (The work is about strengthening underlying bonds, not hoisting up the bondage.)
But some of the renegades think that strong attachment is an ineffective way of creating sparks in the bedroom.
“Couples therapy is very feminized,” Dr. Nelson said. “It’s all about teaching men to be more like women. He should pay attention to her feelings, and if she’s upset, there’s something wrong. We ask him to engage with her like she’s his best friend and then we wonder why she doesn’t want to have sex with him.”
Sex therapy, she said, has been focused on performance, functioning and pharmaceuticals. But the worlds are starting to fuse. “As we get more really good couples therapists in the field of sex therapy it expands the field and we get more crossover.”
When she trains therapists, Dr. Nelson said, “I tell them to ask in the first session, ‘When was the last time you had sex and how was it?’ We’re talking about couples here. Why would you not talk about sex? I tell them, ‘If you’re not talking about sex, you’re perpetuating the idea that they shouldn’t be, and that just won’t help.’ ”