Signs You Need a Sex Therapist: Expert Advice with Nicoletta Heidegger
00:00 On this episode, for people who are born, you know, with a penis, there's sort of this masculinity trope of like, well, I should just be good at sex. You know, you should just be You're listening to the In Your Pants podcast. I'm your host, Dr. Susie Gronski, your penis friendly pelvic health physical therapist, sex counselor, and educator helping you get in the know down below. Today, we're talking about the benefits of seeing a sex therapist. You'll learn what a sex therapist is and how they can support your sexual well-being and the signs when you should reach out to one. We cover genital and pelvic pain in people with vaginas and penises and how incorporating play into sex can actually reduce pain and enhance pleasure. Lastly, our
00:56 guest shares her unique therapeutic approach with horses and how she incorporates equine therapy with discussions around sexual topics and intimacy. Truly one of a kind. So a little about our guest. Nicoletta Heidegger is a licensed marriage and family therapist practicing in Los Angeles. She received her BA in psychology from Stanford, her MA in clinical psychology from Pepperdine University and her Master's of Education in Human Sexuality from Widener University. When not working with clients, she teaches seminars and classes to help others learn about sexual and mental health. If you enjoy listening to this podcast, please be sure to share your favorite episodes and leave a raving review wherever you watch
01:44 or listen. Nicoletta, thank you so much for being on the show today. Thank you for having me. So glad to connect with you. Likewise. So could you elaborate for us what a sex therapist does and how they support their clients in sexual well-being? So a sex therapist is usually a licensed therapist that specializes in issues relating to sexuality and a therapy space where we actually talk about sex. So most therapists, general therapists, only get one class, if at all, and it's usually only about 10 hours, sometimes less. um, in human sexuality. And so sex therapy is usually for folks who have specialized additional training, um, in that topic. And folks usually come see me for a variety of things ranging from pelvic pain to not connecting with their partner, uh, trouble orgasming, being on their gender
02:38 journey and yeah, pretty much across the spectrum. Yeah. And so what are some of the signs and or symptoms and you started to name those that indicate maybe it's time to seek help from a sex therapist like yourself. I mean, I, since I'm a therapist, I really encourage people to do therapy proactively and preventatively as well. You know, just like you learn how to drive a car, you can learn better how to be in relationships and how to have sex. And so unfortunately in our culture, a lot of people still wait until there's a problem or a crisis or things really aren't going well or haven't been going well for years and i get it i understand because for me i think it's just a human thing where we put things off and sort of like the the pain olympics
03:22 a little bit like how long can i deal with this until i can't anymore um and i invite people to go now like go as soon as you can run to it um again i'm biased but i i do think it's helpful to have a lot of tools to yeah like you just deserve to have more pleasure and feel better for folks who are wondering you know topic specific I would say if you're not enjoying the sex that you're having with yourself or with other people if you're experiencing any pain unwanted pain that is during sex if you are in a relationship that you're just not feeling you know in connection to yourself or your partner or you've kind of lost that that spark so to speak if you are feeling alone in any kind of journey that you're having around sexuality orientation
04:15 type of relationship you want to be in if you're looking to open up your relationship to non-monogamy or explore alternative lifestyles or interests and the big one also is if you're feeling shame if you're feeling shame and not in like a fun spicy way of like oh no I shouldn't do that but shame around anything related to sex and relationships and then of course trauma and a lot of us have had trauma in different ways shapes or forms so those are some topics I would say that that bring people in and I would invite you to check in with somebody if you're experiencing any of those. Right. Absolutely. So speaking of shame and embarrassment, what role does stigma, you know, societal stigma play in, in delaying or even wanting to seek help for intimate concerns?
05:09 I mean, I think first off, a lot of people don't even know that folks like me exist. Uh, so they're, they're often surprised when they're like, Oh, you can go see somebody about this. Or like, there are sex therapists there are sex coaches there are sex educate like a lot of people just don't even consider that a concept um and then i think there's this a few misnomers in our society one is the sort of romantic comedy approach which is like well if we're in love then you know that's enough and and we should be able to have great sex and so people think then there's something wrong with them or they're doing something wrong if the sex isn't happening um i think for for different genders as well there's different shame aspects so for people who are born uh you know
05:54 with a penis uh there's sort of this masculinity trope of like well i should just be good at sex um you know you should just be somehow you're just born you're just a sex god um and so there's this pressure around around performance um and then i think for other people it's just self-esteem as well. And just, it's hard to ask for help. And like I said, in this culture of capitalism, we're very much taught like no pain, no gain. And so I think a lot of us get really comfortable with suffering for a long time. And there's a saying, I think it's an AA saying, it might be shit, but at least it's warm, which is kind of like a gross thing to think about. But i think a lot of us do get comfortable in that discomfort and it's hard to it's hard to make a
06:42 change it's hard to do it and we're just freaking busy like there's so many things expected of us life family potentially kids work taxes like just the list goes on and so taking the time to find somebody to look for somebody to call somebody for them to be available to schedule it like it's a lot of steps. So start small if you're interested. Absolutely. And, you know, you named a couple of things there as far as being able to tune into giving permission to oneself to get help for sexuality concerns, because it's often like, well, sexual health, we normalize it that, oh, if it changes or if it's not great, or if it's painful, that it's just, it's due to some other factor, if it's just aging or drink some wine, you'll be
07:29 fine kind of thing. And, and that I think is that's normalizing a very negative message. It's not a very uplifting, positive sex, positive message to say, Hey, sexual health actually matters for your mental health and wellbeing. It is one of the four pillars of, of health, you know, alongside of physical, mental, spiritual, right? So I'm so glad that you, you named that. And speaking of pain, we often talk about penises that experienced pain on this show. And I'd love for you to bring in some insight around pelvic pain or sexual pain for people who have vaginas and how sex therapy can really support a person navigating with genital or sexual pain. Yeah. Thank you for asking that. And you know what? I want to add one more point
08:18 to your question from before, and that's this thing called positive affect tolerance. Some people call it a nourishment barrier, but a lot of us also just struggle to receive, whether that be receiving help, receiving pleasure, receiving support, receiving compliments. So that's another reason I see people struggling is that they don't feel like they can deserve more, more help, more pleasure, all of that. And I think that relates to pain too. And pain can happen in all bodies. And so for people with vulvas and vaginas, it's one of the most common things that I see in my practice. And unfortunately, I think a lot of people are experiencing pain for a long time and normalizing it before they get help or before there's a doctor who actually says, oh, you know,
09:02 there's something you can do about this. Because fortunately, a lot of doctors are not specially trained in that and may not know what to tell a patient or where to send them. So what are some of the contributing factors in your experience that contribute to pelvic pain in you know either people with vulvas and vaginas and and for penis penis havers out there yeah i think for any body it's usually what we call like a biopsychosocial thing meaning it involves uh the body the physiology the mind the psychology uh the sociocultural and the spiritual and so oftentimes there's a one of those things maybe starts the pain and then one of the others or a few of the others maintain the pain. So some of the most common things I see for, um, people with penises,
09:53 um, and I see more people with vaginas who are experiencing pain, but for people with penises, I see issues with like, um, you've probably talked about in the show, but like Peyronie's, um, so like penile fibrosis, um, I see people having nerve issues, back issues, even scoliosis, um, sort of like degenerative disc things that are just affecting their pelvic region. Um, that's probably the most common thing, um, that I see for folks with penises, um, for people with vulvas and vaginas. Um, I see the most common thing I see is something called hormone mediated vestibulodynia, which is a big fucking mouthful, but it basically means hormones are affecting pain at the opening of your vagina at the vestibule. Um, this is often caused by long-term
10:36 birth control use, um, or just changes in aging, um, and how our hormones are being affected. so this can affect the tissue and then once there is pain that starts it can create more pain because then that person is tensing and holding their pelvis to prevent pain from happening or they may just avoid sex entirely both because their hormones are not necessarily signaling a lot of desire but also because their bodies are trying to protect them from pain so that's a big one that I see there's sort of an overarching word that people use which is vaginismus and That's kind of a blanket term I've seen, but usually if someone comes to my practice with pain, I will send them to a sexual medicine specialist to see what's going on with the hormones, with the tissue, and just what might be going on bacteria-wise as well. Um, so yeah, some of the main physical causes, like I said, are hormones, um, an issue, an
11:36 issue with the tissue, uh, and potentially some undergrowth or overgrowth of different kinds of, of bacteria, um, that may naturally live in the body, but are, are undergrowing or overgrowing. Um, and then the last one I see very commonly is something called, uh, endometriosis, which is when basically when tissue is growing outside of where it's supposed to be growing, um, in the pelvic region. And like I said, a lot of folks with this sometimes don't even know they're experiencing pain or they experience it and they just kind of grin and bear it. And then the pain cycle worsens over time and they've gone to doctors and a lot of doctors either don't say anything or are just like, have you tried lube?
12:18 And so there's been sometimes years of this ongoing and it's very frustrating on a mind, body, spirit level. Definitely. And so with your work with folks with these struggles that you're naming, how do you support them in sessions? What are some of the strategies or techniques that you might use? And you mentioned kind of referring out to other professionals to have this be a collaborative approach. And if there are any other professionals that are on your list of go-tos. Yeah. So like I said, first and foremost, when I hear pain, I first send them to a sexual medicine specialist. And unfortunately, these folks can sometimes be hard to come by. If you are looking for someone in your area, you can check out the directory through ISWISH, which is, what is it? I-S-S-W-S-H, International Society for Sexual Health. Yeah, I hope we can put it in the show notes. but they have a directory. Here in Los Angeles, I refer to two doctors. One's named Dr. Lisa Valle, who I've had on my podcast. And another is Dr. Joshua Gonzalez, who I've also had on my show. The unfortunate thing is a lot of times they might not take insurance or they may not take all the insurances because it is specialized and a lot of insurances don't cover. So I just want to name that there is an unfortunate accessibility barrier. And this is a systemic
13:46 issue that, uh, organizations like tight-lipped, uh, that exists out there are putting in efforts to combat. Um, so that's first and foremost is I kind of introduce them sometimes for the first time that there are doctors out there who know about this, who have this specialization, who you can talk to. And then things that we are going to work on, um, is once they see that person, they may also have another person added to their team, which is a pelvic floor therapist. to do that work physically and so once they have kind of the physical support I come in for the mental emotional you know community support so things we're dealing with are shame so we're working a lot with feelings of shame we're working a lot with feelings of anger as well because some
14:36 people are freaking pissed that nobody ever taught them about this or that there were things they didn't know when taking birth control or doing certain things so we're processing a lot of anger i'm connecting them with community as well for other people that are experiencing this because community is key we're working a lot with slowing down and making sure they're also prioritizing pleasure and feeling that they are still in a body that is pleasure able so we're looking at things like redefining sex and pleasure potentially away from penetration for the time being to help them find new ways, sometimes sexual, sometimes not, of being safe in their body, feeling pleasure, teaching them relaxation, breathing techniques, ways to come back to their body
15:24 and feel safety. And then we're also working on self-esteem and self-confidence so that they can advocate for themselves to the doctors that sometimes they know more about this then than the doctors they go to do. Um, so those are a few of the things, but I think the main thing ends up being like pleasure practices, creativity, work, and an advocacy. And speaking of pleasure practices, I know you're a huge advocate of play and bringing playfulness into one's life, not just sexually, but why is play so essential for adults, especially
16:01 when navigating pain, which can often lead to burnout. I mean, just like you said, feeling really frustrated with their situation, with life in general. Where does play come in? So play is, in my opinion, and not just my opinion, research shows, too, that play and pleasure are essential for human survival and just for so many things that we do in life. Unfortunately, in this culture, we're taught that it's something that you get to do after you do the work, right? after you do your homework, you can play. After you feel better, you can play. After your body is not in pain, you can have pleasure and play. But it is more of an essential tool towards healing that we can use for those things. So play is how we learned about the world when we were younger
16:49 growing up. And so it is the way that we make meaning, that we are creative, that we engage with the world around us. It's also how we form new neural pathways in our brain. So it supports neuroplasticity. Um, it can increase self-esteem, uh, self-confidence and just elicit feel good neuro chemicals and hormones, um, in our body that help us to want to do things more, right? Like if you're just coming to therapy or the work that you're doing is all just like trauma processing pain, like, excuse my language, but like who the fuck would want to keep doing that? And so, yes, that's important. And we need something to keep us going and engaged. And that's giving us some conditioning support that it's worth doing. And so pleasure and play really are this essential tool in healing. And so that can be hard for people who are in a body that's experiencing pain or just for any of us who grew up in this culture that does emphasize work and productivity.
17:54 But just remembering that if you don't invest time in that, you are going to burn out and be less productive overall. So I do a lot of work with people sometimes outside in nature. I also work with horses and animals, kind of helping people come back to their sense of play without goals. And yeah, it's just been a key part of healing in my life and for so many of my clients. I'm so glad you brought up your unique specialty in equine therapy and how you're incorporating that into your sex therapy sessions with people. I'm really curious about this. This is the first time I've heard of sex and horses in a non-beastiality way. Thank you for naming that. Yes.
18:43 Thank you for naming that. Yes, absolutely. It's like we've heard of that, but in a different context. So yeah, absolutely. Yes. Talk to us about the uniqueness of equine therapy and how you bridge this therapeutic integration into your sessions. Yeah. So I moved my office to a ranch, which is very cool. We've got horses, pigs, goats, sheep, alpacas. It's called Special Spirit. They also do a lot of other therapeutic and animal learning activities there in Los Angeles. So
19:14 if you're interested, check it out. And the way that it works is we can work on things in real time in an experiential way. So instead of us just like talking about dynamics that people have in their relationships, we get to kind of practice seeing them play out with the support of like a nonjudgmental creature. So horses are really great at just sort of like taking care of their moment to moment needs without shame. They're like, if I need water, I get water. If I need to itch i itch if i want to play i play i want to roll in the dirt i roll in the dirt so sometimes they're just a great model for people to be like oh my gosh you can just have a an instinct desire and go do that um amazing uh other times it's just about connecting with another sentient
20:00 non-judgmental creature um that is a prey animal so they're really good at picking up one when we're not being authentic. And so they just kind of invite us to slow down, be present, be authentic. I've seen equine work be really helpful for things like trauma, anxiety, depression, perfectionism, and even for sex and relationship stuff. So just to give an example of how that could look, for example, sometimes I do parts work with people. So there's a approach called internal family systems where we all have like different parts of ourselves that we work with. So for example, I might have them pick a few different horses and each horse sort of represents a part of themselves based on what they observe in that horse. And then we do a series of exercises
20:49 and activities where they're connecting, bonding, moving around and creating relationship with those different parts. Another way I've done it in the sex specific realm is sometimes I'll have them build an obstacle course that represents the kind of connection and intimacy they want to have. And then they have to bring that equine, that horse or donkey through that obstacle course. And through that, I get to see what happens in their actual process of how they get stuck, where they get stuck. And it's shown in real time and they get to work through it in real time. So it's a really cool healing modality that has a lot of options and things that one can do that are not, yeah, not what you think in the kinky way with sex and horses, but it's all about relationship building and attunement and connection and slowing down, mindfulness, and so many things like that. Yeah, I really love your approach.
21:49 I really think it's truly unique because you're integrating reflection and insight in an active exploration kind of way to support and facilitate building resilience, self-efficacy, and really adapting, helping their body adapt to a particular way that is going to be more liberating for that individual. So I think it's really awesome. And it's truly unique in its own right. So it's really awesome. So appreciate the work that you do and for sharing your passion with us today on the show. For the listeners and viewers out there who want to connect with you, where do you live on the interwebs these days? Thank you so much for having me. And thanks for all that you do for our field as well. I am on Instagram at Sluts and Scholars, which is the name of my podcast that you can also find wherever you get your podcasts. I'm also at Therapy with Nicoletta. You can find the episode and me through slutsandscholars.com and as well as my personal website on my Instagram. And yeah, wherever you get your podcasts is where you can find me. That's awesome. And we'll be sure to link all of that and the resources you shared with us in the show notes from today. Again, thank you so much, Nicoletta. Really appreciate you being here. Thank you for having me. And to all of our viewers and listeners out there in loving wellness for your pelvis, this is Dr. Susie G. Until next time. Thanks for listening to today's episode. Be sure to visit my website, drsusieg.com for show notes and related resources on today's
23:36 topic. If you like what you're hearing head on over to YouTube and subscribe to my channel. On my YouTube channel you'll find content related to sex, pelvic health, and expert interviews for men. If you got a question or a topic that you'd like me to answer on my channel be sure to type it in the comment box below.
There aren't comments yet for this episode. Click any sentence in the transcript to leave one.