The conversation that keeps not happening

Sex therapy in California — for what's gotten hard to talk about.

Online sex and intimacy therapy in California for individuals and couples. For changes in desire, arousal, performance or pleasure, and for the shame and silence that so often build up around them.

Reviewed by Marjolaine Bernstein, AMFT (CA BBS #164685) and Jasmeet Bhullar, LMFT (CA BBS #117019) Updated October 2026

For a lot of people, the hardest part of a sexual concern isn't the concern itself. It's that there's nowhere to say it out loud. Sex therapy is talk therapy for concerns about desire, arousal, performance, orgasm, pain or satisfaction, whether you're single, dating, or in a long-term relationship. Sometimes it looks like a loud problem: sex that hurts, a body that stopped responding, a partner who has stopped asking. Sometimes it's quieter. Desire that drifted somewhere and never came back. A yes that doesn't feel like a yes. A conversation that keeps not happening. Both are common, both are treatable, and neither one means something is wrong with you.

What sex therapy is.

Sex therapy is a specialized form of psychotherapy. It's fully talk-based: no touch, no exams, no one is asked to undress. What makes it different from general therapy is that sex is allowed to be the main subject rather than something that comes up in passing in session eight, and the therapist has training in how sexual concerns tend to develop and what tends to help.

People come in with all kinds of things. Some say something like, we used to want each other, and I don't know when that stopped. Some say, my partner wants it more than I do, and I feel like I'm failing. Some just say, I feel broken. Many of the people we work with have carried that last sentence for years before saying it to anyone.

Sexual concerns are also some of the most common concerns adults have, and some of the least discussed. Desire discrepancy, where partners want sex at different amounts or in different ways, is one of the most frequent reasons couples look for sex therapy. That doesn't make it easy to live with. But it may help to know how ordinary it is.

One honest note about language. Two of our clinicians, Marjolaine Bernstein and Jasmeet Bhullar, are members of AASECT (the American Association of Sexuality Educators, Counselors and Therapists) and are working toward the AASECT Certified Sex Therapist credential. Neither is certified yet, and we'd rather tell you that plainly than let the word "certified" do work it hasn't earned.

Framework

Body, story, between — the three places desire lives.

Most of what's written about sex treats desire as one thing that's either there or not. In our practice we've found it more useful to think of desire as living in three places at once. When something changes, it can help to get curious about which place is asking for attention.

The body. Hormones, medications, chronic illness, pain, sleep, pregnancy and postpartum, menopause, the stress you carried home from work. Marjolaine has written about this directly: sometimes the relationship is the problem, but sometimes it starts as a body problem. Antidepressants, hormonal birth control and thyroid or pituitary changes can all shift desire or arousal, and none of that is a character flaw.

The story. What you learned about sex before you ever had any. What your family said, or didn't. What your culture or faith taught you to want, or not to want. Past experiences, including painful ones. And the story you've started telling about yourself since things changed, which is often some version of I'm broken or I'm failing them.

The between. The relationship itself. Resentment that never got named. Whether it feels safe to say no, or to ask for something. How the two of you talk about sex, if you do. Sometimes the between is where the problem started. Sometimes it's simply where it ended up.

The three places don't stay separate for long. A body change can turn into a story (something is wrong with me), which can turn into avoidance between partners, which adds pressure back onto the body. Marjolaine calls this a shame spiral, and it's one of the most common patterns we see. The spiral can be interrupted at any of the three points. That's often the most hopeful thing we can tell someone in a first session: you don't have to fix everything at once to start feeling some relief.

Sometimes desire hasn't disappeared at all. It may be waiting on something the body, the story, or the space between you is asking you to notice.

What we work with.

Sex therapy covers a wider range than most people expect. These are some of the concerns people bring to us, for themselves or as a couple:

  • Changes in desire: wanting sex less, wanting it more, or wanting it differently than a partner does (desire discrepancy)
  • Arousal and performance: erectile concerns, arousal that doesn't match wanting, performance anxiety that shows up before anything starts
  • Orgasm: difficulty reaching orgasm, timing concerns including premature or delayed ejaculation, or feeling disconnected from it
  • Satisfaction and skills: sex that's become routine, not knowing how to ask for what you want, or never having been taught much about pleasure at all
  • Pain with sex: including vaginismus and dyspareunia, alongside your physician or a pelvic floor physical therapist
  • Medical conditions and medications: hormonal changes, chronic illness, fertility treatment, pregnancy and postpartum, and medication side effects that affect sexuality
  • Sexual trauma in your background, and the way it can show up years later in intimacy
  • Questions about sexual orientation or gender identity, whether you're exploring, newly out, or somewhere in between
  • Sexual compulsivity, including porn use or sexual behavior that feels out of your control
  • Intrusive sexual thoughts that feel unwanted and distressing, which sometimes turn out to be OCD

We're affirming of LGBTQ+ clients, of people in consensually non-monogamous relationships, and of kink. You won't have to explain or defend your relationship structure or your orientation before we can get to what you came in for.

If part of what you're carrying is a yes you don't always mean, Marjolaine wrote about that pattern in The exhausting yes. If the difficulty is saying the real thing to a partner, Jasmeet wrote The voice you find with your partner in the room and The disputes your partner didn't know were disputes. And if intimacy got ahead of the conversation, Elaina wrote The situationship.

Why it happens.

There's rarely a single cause, and naming yours tends to shape the work. Maybe one of these fits. Maybe several do.

  • Physical and medical changes: hormones, medications, illness, pain, fatigue, aging
  • Stress and anxiety: a nervous system that's on alert has a hard time also being open to pleasure
  • Shame and messaging: what you were taught about sex, bodies and wanting, often without anyone saying it directly
  • Relationship dynamics: unspoken resentment, pursuit and withdrawal, one partner becoming "the one with the problem"
  • Past experiences: painful or traumatic experiences, or earlier relationships that changed what feels safe
  • Life transitions: a new baby, a move, a diagnosis, a career that takes everything, or a relationship that has simply gotten long

Sometimes it's avoidance. Sometimes it's exhaustion. Sometimes it's both, and that's fine too. Understanding where something comes from is how we figure out where to start. Nobody here is keeping score on whose fault it is.

How sex therapy helps.

Much of sex therapy training is organized around a four-level model called P-LI-SS-IT, developed by psychologist Jack Annon in the 1970s and still widely used, including in AASECT's own descriptions of the field. The levels build on each other, and many people get real relief in the first two or three.

  • Permission: creating a space where sex can be talked about without embarrassment, so it's treated as the legitimate health concern it is. For some people, this alone is a relief they've waited years for
  • Limited Information: correcting the myths and misinformation that so often sit underneath a concern, like the idea that desire is supposed to be spontaneous, or that erections and orgasms are a reliable measure of attraction
  • Specific Suggestions: building a sexual history together (what the concern is, how it developed over time, what's driving it), and then working toward realistic goals with concrete communication tools and exercises you try privately at home
  • Intensive Therapy: longer, deeper psychotherapy when a sexual concern is tangled up with something else, such as anxiety, OCD, depression, trauma, substance use, or conflict within yourself or with a partner

Sexuality counselors, who include nurses, health educators and other professionals, are trained in the first three levels. Sex therapists are psychotherapists who can also provide the fourth. Every clinician at Align is a California-licensed or registered psychotherapist, which means that when a sexual concern turns out to be connected to something larger, we don't have to hand you off to start over somewhere else.

Alongside that structure, the work draws on CBT for the anxious thoughts that crowd out arousal, mindfulness-based practices for getting out of your head and back into your body, attachment and Emotionally Focused Therapy for couples, and EMDR and IFS where trauma is part of the picture. For more on how this kind of work changes the brain over time, see Why Therapy Works.

An honest limit: change here is rarely linear. Some weeks a conversation opens something up, and some weeks old patterns come back. Sometimes the work means doing less, and letting what's underneath finally have room.

Our approach at Align.

Marjolaine anchors this work, and she starts from curiosity, the kind that doesn't rush to make one person the problem. A lot of her early work is psychoeducation, because understanding what the body and nervous system are doing is often the first thing that loosens the shame. Jasmeet brings the couples and premarital side: getting underneath the argument you keep having to the question each of you is actually asking, and, before a wedding, talking about expectations around sex while they're still easy to adjust.

When something medical may be involved, we'll say so early and coordinate with your physician, gynecologist, urologist, endocrinologist or pelvic floor physical therapist. Therapy and medical care tend to work best together.

Every clinician at Align holds a Master's in Clinical Psychology with an emphasis in Marriage and Family Therapy from Pepperdine University, and the whole team trains together in weekly supervision. Sessions are weekly, 50 minutes, online, with a California-licensed or registered therapist. $200 per individual session, $250 per couples session.

Sessions are available in English, Spanish (Fidel Quintanilla), and Hindi and Punjabi (Jasmeet Bhullar).

Who does this work.

Marjolaine and Jasmeet lead sex therapy here. Three others meet sexual and intimacy concerns where they overlap with their own specialties.

  • Marjolaine Bernstein, AMFT — therapist at Align Online TherapyMarjolaine Bernstein, AMFT (CA #164685) — reviews this page and leads sex therapy at Align. An AASECT member working toward the AASECT Certified Sex Therapist credential, she works with individuals and couples on arousal, performance, satisfaction, and desire that has dropped, risen, or stopped matching a partner's. She has written about how hormonal changes can set off a sex shame spiral (Pituitary World News), and her work leans on psychoeducation, because understanding what the body is doing is often what loosens the shame first. Also a member of the International OCD Foundation (IOCDF), which matters when intrusive sexual thoughts are part of the picture. CBT, mindfulness, attachment-informed work, ERP and psychoeducation.
  • Jasmeet Bhullar, LMFT — therapist at Align Online TherapyJasmeet Bhullar, LMFT (CA #117019) — co-reviews this page and takes intimacy inside couples and premarital work. An AASECT member working toward the AASECT Certified Sex Therapist credential, founder and Clinical Director, 15+ years in practice. In couples work he draws on attachment and Emotionally Focused Therapy to get underneath the surface argument to the question both people are really asking; in premarital work, the goal is to make the invisible expectations about sex visible before they become resentments. Adjunct faculty at Pepperdine University. CBT, attachment, EFT, existential and Bowen Family Systems.
  • Julia Melvin, AMFT — therapist at Align Online TherapyJulia Melvin, AMFT (CA #137797) — takes the intimacy concerns that sit on top of sexual trauma, using EMDR and Internal Family Systems at a pace that never asks more than you can hold. She also works with the changes in sex and desire that can come with fertility treatment, pregnancy, birth and new motherhood. EMDR-trained; IFS practitioner. EMDR, IFS, attachment, CBT and mindfulness.
  • Fidel Quintanilla, AMFT — therapist at Align Online TherapyFidel Quintanilla, AMFT (CA #125756) — takes performance pressure, including the erectile and orgasm worries many men were never given language to talk about, and the high-achiever habit of treating sex like one more thing to execute well. Direct and present-focused, and comfortable making a hard conversation feel less grim. Adjunct faculty at Pepperdine University. EMDR, ACT, CBT, EFT, mindfulness and attachment.
  • Elaina Envia, AMFT — therapist at Align Online TherapyElaina Envia, AMFT (CA #149268) — takes intimacy in dating and new relationships: the situationship where sex came before any real conversation, the pressure to perform confidence you don't feel, and the self-worth that gets tangled up in whether someone wants you. Warm, direct, honest; CBT, attachment and solution-focused work.

All associates are supervised by Jasmeet Bhullar, LMFT #117019.

What our students and peers say

Because we don't solicit client testimonials as a policy, the voices below come from former graduate students. Marjolaine isn't in a teaching role that produces public testimonials, so these describe Jasmeet, who co-reviews this page and supervises her clinical work. What they describe is the same presence our clients meet in session.

"He has an amazing way of commanding the classroom with warmth and authenticity while also making room for discussion, curiosity, and differing points of view." Katie Byam, MFT Trainee on Jasmeet Bhullar, LMFT
"He skillfully breaks down complex and otherwise abstract theories and ideas into practical, functional tools." Jonathan Griffin, MFT Trainee on Jasmeet Bhullar, LMFT
"His feedback and direction was specific to the student and their unique style/approach as a clinician." Val Posada, MFT Trainee on Jasmeet Bhullar, LMFT

Read all our teaching and colleague testimonials →

Who we work with.

Adults across California, individuals and couples, of all genders, orientations and relationship structures, most often in their 20s and 30s. People who have been quietly managing a sexual concern for a long time, people whose relationship has hit a stretch where intimacy got hard, and people who have never had anywhere to ask the questions they've been carrying. Some arrive already knowing what they want to work on. Some just know something feels off. Either is a fine place to start.

What we don't do.

Sex therapy at Align is talk therapy only. There is never physical contact, physical examination or any sexual activity in session. Any exercises are done privately, at home, on your own or with a partner. We don't prescribe medication or diagnose medical conditions; when something may be physical, we'll coordinate with the right medical provider.

We don't provide court-ordered or forensic treatment, including evaluation or treatment related to sexual offending. We don't treat children or adolescents. And if sexual compulsivity or substance use has reached the point where you need daily structure, an intensive outpatient program or residential care, we'll tell you that honestly on the consultation call and help you find the right setting.

If you are in crisis: call or text 988 for the Suicide and Crisis Lifeline, available 24/7 anywhere in the US. If you or someone else is in immediate danger, call 911. If you have experienced sexual assault, RAINN's National Sexual Assault Hotline is available 24/7 at 800-656-4673. Align does not provide emergency or after-hours crisis services.

Sex therapy: common questions.

What happens in a sex therapy session?

Sex therapy is talk therapy. Sessions are 50 minutes, online, and fully clothed, the same as any other therapy appointment. There is no physical contact and no physical exam. Early sessions usually include a sexual history: what's changed, when, what you've already tried, and what you were taught about sex growing up. From there the work might include information that corrects common myths, conversations you practice having, and sometimes exercises you do privately at home, on your own or with a partner, and then talk through in session.

Is sex therapy only for couples?

No. Many people come on their own, whether they're single, dating, or partnered and not ready to bring a partner in yet. Couples sessions are available too, and some people move between the two. Individual sessions are $200 and couples sessions are $250.

What's the difference between a sex therapist and a sexuality counselor?

Sex therapy training often uses a four-level framework called P-LI-SS-IT: Permission, Limited Information, Specific Suggestions and Intensive Therapy. Sexuality counselors, who include nurses, health educators and other professionals, are trained to work in the first three levels: making room for the conversation, correcting misinformation and offering concrete suggestions. Sex therapists are psychotherapists who can also provide the fourth level, longer-term therapy for concerns tangled up with anxiety, OCD, depression, trauma or relationship conflict. At Align, every clinician is a California-licensed or registered psychotherapist, so we can work at all four levels. Two of our clinicians, Marjolaine Bernstein and Jasmeet Bhullar, are AASECT members working toward the AASECT Certified Sex Therapist credential.

What are the three places desire lives?

In our practice we describe desire as living in three places at once: the body (hormones, medications, illness, pain, sleep and stress), the story (what you learned about sex, from family, culture, faith and past experiences, including shame and trauma), and the between (the relationship itself, including resentment, safety and how you talk about sex). A change in one place tends to ripple into the other two. A body change can turn into a story about being broken, which can turn into avoidance between partners, which adds more pressure on the body. A useful first question is often which of the three places is asking for attention.

Is it normal for partners to want sex at different amounts?

Yes. Desire discrepancy is one of the most common reasons couples seek sex therapy, and it is rarely a sign that one person is broken or the relationship is failing. In sex therapy, some people find it helpful to learn about responsive desire: desire that shows up after closeness or arousal begins, rather than before. For many people that's how desire has always worked, and it can feel very different from the spontaneous kind most of us were told to expect. Much of the work is understanding what each person's desire responds to, so neither of you has to keep tracking the gap.

Should I see a doctor before or alongside sex therapy?

Often, yes. Pain with sex, erectile changes, a sudden drop in desire, or changes after starting a medication, pregnancy, birth or menopause can all have medical causes worth ruling out. We'll ask about this early and coordinate with your physician, gynecologist, urologist, endocrinologist or pelvic floor physical therapist when it helps. Therapy and medical care tend to work best together. As Marjolaine has written, sometimes the relationship is the problem, but sometimes it starts as a body problem.

Can sex therapy be done online, and is it private?

Yes. Because sex therapy is talk-based, it works well over video, and many people find it easier to say difficult things from their own space. Sessions are confidential. If privacy at home is hard, some people take sessions from a parked car or a booked room, and we'll help you plan for that.

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