Some sexual problems related to MS are direct effects of the disease, such as reduced vaginal lubrication or erectile dysfunction due to neurological impairment. But MS can also indirectly lead to many sexual problems, such as reduced sexual desire due to fatigue, logistical issues related to limited mobility, or changes in whether you view yourself as sexually desirable. Certain sexual problems can and should be addressed in partnership with your neurologist or primary care doctor. But another member of your medical team may be able to help you deal with sexual issues directly or indirectly related to your MS: a sex therapist. Many people have misconceptions about what a sex therapist does and why an individual might choose to see one. Here are some of the reasons seeing a sex therapist may be especially beneficial if you have MS, and what you should know before showing up for your first appointment.

Anyone experiencing problems or frustration related to their sexuality may benefit from seeing a sex therapist. There are a few likely scenarios in which people with MS fall in this category. Low libido, or sex drive, is very common in people with MS, says Kimberly Castelo, a licensed marriage and family therapist and certified sex therapist in Seattle. “It comes a lot with desire discrepancy,” or having a lower sex drive than your partner, and is often related to feeling exhausted or like you don’t have any time for sex due to your MS. Even though vaginal pain or dryness — or erectile dysfunction — may be related to underlying medical problems that need treatment, a sex therapist may also be able to help you adapt to these issues. “We can talk about what kind of lube they’re using, or if they’re having pain, we might refer out to a gynecologist or pelvic floor specialist,” says Castelo. And even though erectile dysfunction may be rooted in a physical problem, it often creates psychological distress or a sense of failure that can make things worse, Castelo says. Working through these feelings, and their effect on your sex life, is something a sex therapist can help with.

A sex therapist can also help you work through problems that aren’t related to your MS or physical condition, such as any sexual trauma you may have suffered. That can include overt abuse, such as rape or molestation, or sexual shame you’ve been made to feel — either from partners or as part of your upbringing. You don’t have to be in a relationship to benefit from sex therapy. While many people with MS are looking to improve their sexual connection with a partner, Castelo says, others are looking to feel more confident as they go about dating, while still others want to feel sexually fulfilled without another person in the picture. If you have a partner, you can choose whether you’d like to attend therapy sessions with them or by yourself, says Castelo. If you intend to go to therapy together, it’s a good idea to look for a sex therapist who is also a couples therapist, or who has experience working with couples.

Expanding the Definition of Sexuality

A sex therapist’s job is to talk about problems or frustrations you’re experiencing related to your sexuality, and help you develop strategies to overcome them. While it’s important to discuss your specific problems, this should be done in the context of getting a broader picture of your sexuality, says Castelo. “We’re going to get a sex history. What messages did you receive about sexuality while growing up? Was there any sexual trauma? How has your relationship to sex changed since you’ve had MS?” For many people with MS, one goal of sex therapy is to help expand your definition of sex and sexuality. “It’s not just genital-to-genital contact,” says Castelo. “It’s about connection and pleasure, and reproduction if you so desire.” Realizing that sexual intimacy doesn’t have to fit a certain image is immensely freeing for many people with MS, says Castelo. She encourages individuals and couples to explore what feels good and helps them feel connected, which can involve any type of contact with any area of your body.

Techniques to Build Sexual Desire

To help people with MS overcome low libido or exhaustion, Castelo often recommends a technique she calls “simmering.” This involves consciously building up erotic tension with your partner, even if you don’t intend to engage in sexual activity soon. “If you’re wheelchair-bound, if you’re tired, whatever you’re feeling, you can tell your partner they’re sexy. You can say, ‘I love kissing your lips,’ but there’s no pressure to kiss” at that moment during the simmering exercise, she says. Being “erotically playful” throughout the day can help people with MS and their partners tap into a cycle of arousal that they may have been neglecting, Castelo says. That means when you’re finally ready to engage in sexual activity, you’ll have built up excitement for the moment.

Treating and Coping With Physical Problems

A sex therapist can also discuss physical problems, like sexual pain or erectile dysfunction, to help make sure you’re getting any needed medical attention, and help you adapt to any remaining issues after medical treatment. “With pain issues, we talk about: Does heat help? Does ice help? Massage?” says Castelo, adding that many people with MS enjoy a sensual massage with their partner before engaging in any erotic play. And for erectile dysfunction, “I’m going to focus on how it’s okay to have a flaccid penis,” Castelo emphasizes. “It can still be pleasurable and fun to engage with,” with partners incorporating manual, oral, or full-body stimulation.

Getting Started With Sex Therapy

Many people are understandably nervous about discussing their intimate lives with a sex therapist. That’s why it’s important for a therapist to help you feel comfortable in an initial meeting, and for you to choose a different therapist if you don’t feel like it’s a good fit. You should also look for a therapist who is willing to collaborate with the rest of your healthcare team, Castelo says. In the beginning of therapy, “It’s very casual, and you just begin to talk,” says Castelo. “We get to know you, and let you know that you’re okay, and that there’s help available.” Once you’ve developed a rapport with your sex therapist, you can discuss what your goals for therapy are. Your specific issues and what you’d like to achieve will help determine how often you go to therapy, and how long your therapy will continue. Sex therapy doesn’t have to happen weekly, and some people can achieve their goals in as few as six sessions, says Castelo. But if you’ve experienced sexual trauma or have deeply rooted problems to overcome, coming in every week may help, and it may take longer to make significant progress depending on the person.

Paying for Sex Therapy

Sex therapy is treated as an out-of-network service by most insurance plans, so it may involve an out-of-pocket expense. You can talk to your therapist about insurance coverage and how to discuss reimbursement with your insurance company. If you need financial help to see a sex therapist, Castelo recommends looking into any assistance programs offered by your local chapter of the National Multiple Sclerosis Society.

Allowing Sexuality to Be a Source of Fulfillment

Helping people with physically limiting health conditions like MS can be especially rewarding as a sex therapist, Castelo says. That’s because your erotic life can be a source of fulfillment even when you feel limited in other ways. “I think it gives us a lot of hope and helps our overall quality of life,” she says, when you feel like “it doesn’t matter what I can do or can’t do, my mobility. I’m an erotic being, and I can feel sexy and handsome and strong even when other parts of my body don’t feel that way.”