Two weeks ago, an expose in Makor Rishon, a Hebrew newspaper identified with the national religious public, revealed a “shameful” secret. According to the article, many newly and not so newly married couples in the religious community experience difficulties in their intimate lives, and find sexual activity to be uncomfortable, unsatisfying and infrequent. The author of the piece, Revital Vitelson Jacobs, reported on Facebook that after the article appeared, she was inundated with emails from readers who responded with their personal narratives. She also heard from coaches, counselors, rebbitzens and kallah instructors (women who prepare Orthodox Jewish brides for their intimate married lives) requesting that she let the public know that they can help. This prompted Vitelson Jacobs to publish an optimistic “help is available” follow-up article. Subsequently, she posted a list of names on her Facebook page, where the offers to help by various professionals, with and without certification or training, continue to appear until today.

Kudos to Vitelson Jacobs for raising awareness and for offering solutions. Couples who experience difficulties in their intimate lives often feel isolated, and it helps to know that if you are one of those couples, you are not alone.

But how is a couple to know who is qualified to provide appropriate assistance? In Israel, there is no one governing body that certifies lay and professional practitioners. What credentials should be sought ? Should the problem be addressed by a medical or mental health professional? If a couple gets married and is unable to consummate their marriage, do they really need a sex therapist (an intimidating and slightly creepy/scary sounding title)? Or, do they just need some additional guidance and instruction from the kallah instructor?

How does being Orthodox affect sex? In 2009, a group of colleagues and I conducted a study that compared sexual satisfaction in women who observe the laws of Taharat Hamishpacha (Jewish Family Purity) to married women in the general population. We sought as well, to study the effect of restrictive sexual values and messages, sexual experiences, and education received about sexuality, on emotional and sexual satisfaction . One significant finding was that the majority of women in our sample of 380, reported feeling that they were not educated in the basics of sex and did not feel sufficiently prepared on their wedding night to engage in intercourse. We also revealed great diversity amongst the content and messages reported to have been received by kallah instructors.

The results of our study also revealed, that many women felt anxious and pressured by the messages they received. “Even though I never touched a boy in my life, I was told we have to go all the way on the first night, because it would be too hard for my husband to wait.” Also noted, was the message that they should be willing to engage in relations as often as their husband needs to. As one woman indicated “I was told that I would eventually enjoy it, but I didn’t, I just understood that it was something I am supposed to do for my husband.”

Other women reported positive experiences with their kallah teachers, such as receiving information about anatomy, sexual pleasure, and the fact that their new husband was obligated to ensure their satisfaction. Many reported that their kallah instructors indicated availability for follow up, if the couple experienced problems.

Sexual problems generally refer to difficulties in sexual function. However, if individuals or couples report having difficulty, yet have no sexual experience, and minimal information and preparation, there may not be a problem of sexual function. Simply receiving the correct facts and information can often resolve the issue. This type of intervention may be provided by educators and guidance counselors who can fill in the knowledge gaps and empower couples to seek professional help as necessary. However, these individuals should have a background in sexuality education and guidance, from institutions such as the Yahel Center for Jewish Intimacy. The instructors who are trained at Yahel, are able to provide basic information and advice consistent with Jewish values and halacha (Jewish law). Moreover, they are committed to promoting an agenda that values women’s autonomy and satisfaction and reduces the pressure on both partners to consummate the marriage before they are ready. The individuals who attend these courses are not trained, however, to actually treat sexual function problems.

Sexual function problems in women refer to difficulties in the areas of desire, arousal or climax, and can include pain, anxiety and/or difficulty with allowing intercourse to occur.  Men may experience decreased desire, erectile dysfunction or rapid or delayed climax. Individuals experiencing a sexual dysfunction may want to begin by seeing a doctor. Erectile dysfunction, for example, apart from being a troubling symptom, can be a marker for heart disease. Painful intercourse may indicate a hormonal issue that can be easily addressed by a gynecologist or it can involve a muscular component that a physical therapist can treat.

Couples therapists may view sexual problems as not solely related to the individual pathology of one partner. Rather, they may look at how the couple organizes around the problem, or how dynamics between the couple may be perpetuating it. Therapists help clients recognize how unhelpful and negative thoughts and anxieties of both partners can increase distress. They often provide behavioral exercises such as improving communication skills, and mindfulness -based techniques to enhance pleasure and reduce the focus on performance. Couples may also experience conflicts and power struggles around sex in the absence of specific sexual function problems.

When sexual problems persist or are unresolved by standard educational medical, and behavioral interventions, psychotherapists understand that a deeper process of treatment may be necessary. By exploring thoughts, feelings and behaviors, and delving into early relationships, the psychotherapy process helps to develop one’s sense of self, including the sexual self. In some cases, past trauma or abuse is a core component that must be processed. If this type of treatment is necessary, it is important to ascertain that the professional is a trained and/or licensed psychotherapist with a Master’s degree in social work, clinical psychology, or counseling. Sex therapists must complete one of these degrees as well as undergo additional education and supervision . Therapists referring to themselves as sex therapists should provide evidence of certification in sex therapy by a recognized professional body such as the American Association of Sex Educators, Counselors and Therapists or the Israeli Sex Therapy Society.

So, getting help may involve peeling some layers. First, the couple needs to talk with someone with whom they feel permission to speak freely. They should feel they are being listened to with empathically and without judgment. It is important to acknowledge that there exists a continuum of comfort levels among people regarding sexual content and language and permission implies laying the ground for frank, culturally sensitive and professional discussion. Then, the couple should receive information and specific suggestions. Counselors, doctors and medical professionals with the proper training and who are not therapists, can provide these interventions. Intensive therapy, however,  is the domain of certified and/or licensed professionals.

Vitelson Jacobs reported that among religious couples, the inability to consummate the marriage is a virtual epidemic. While some may find this surprising, therapists have been aware of this issue for some time, and my colleagues and I have reported on our clinical experiences and expertise in the academic literature here, here and here. Here too, we emphasized that often, simply providing basic information may be sufficient. However, when that isn’t enough, additional intervention may be necessary.

It should be pointed out that the journey to sexual fulfillment is not solely about improving function. Sex is not simply something you “do” or accomplish, and should not feel like a chore or something you “provide”. Rather, it is something you experience, or as my colleague Esther Perel says “it is a place you go.”

Ultimately, sex can be valued and appreciated in many different ways and provides the opportunity to experience joy, pleasure, intimacy, satisfaction, security, bonding, playfulness and even a spiritual connection. Sex can be an expression of passion, creativity, and love. It involves holding on to yourself, while letting go, feeling secure while taking risks, being in the moment with all your senses while trusting, accepting and sharing. When it isn’t working, there may be more to it than knowledge, techniques or positions. Individual and/or relationship issues may be underlying. The ability to help navigate through the distress may require peeling off some layers of complexity beyond providing advice, and may require the skill of a trained and certified professional.