Barriers to Seeking Treatment for Sexual Difficulties in Sex Therapy

Abstract Despite a high prevalence of sexual difficulties, many individuals never seek or receive care. Although several studies have established barriers to help-seeking for sexual difficulties within general practice, few have assessed barriers specific to sex therapy. This study aimed to understand the barriers to seeking a sex therapist for sexual difficulties. A total of 27 individuals aged 19–53 participated in unmoderated structured interviews. Thematic analysis identified five themes: accessibility and cost, partner engagement, psychosocial factors, confidence in own abilities, and perceived severity. The study highlights new insights into barriers to sex therapy that preclude seeking help for sexual difficulties.


Introduction
Previous research has indicated that sexual difficulties are widespread, with around half of men and women reporting an issue with their sexual functioning in the previous 12 months (Mitchell et al., 2013).Sexual difficulties can result in significant repercussions for well-being, sense of self, and quality of life (Balon, 2017;Rowland & Kolba, 2018;Ventegodt, 1998).While a broad range of sexual difficulties exists, diagnoses primarily focus on desire, arousal, and/or orgasm issues.Despite the documented effectiveness of treatments, a high proportion of individuals do not seek or receive care (Moreira et al., 2005;Williamson et al., 2019).As a result, many sexual difficulties never receive a diagnosis or treatment (Akre et al., 2010).A large population-based survey in Britain found that more than half of men and women with distressing sexual difficulties in the past year had not sought help, although there appear to be substantial variabilities in help-seeking patterns between cultures (Mitchell et al., 2016;Nicolosi et al., 2005).Delaying or avoiding treatment may result in harmful secondary consequences such as interpersonal and relational distress alongside decreases in self-esteem, sexual pleasure, and overall life satisfaction (Patrick et al., 2013;Woloski-Wruble et al., 2010).Thus, it is imperative to improve understandings of why people may not seek help from a sex therapist for sexual difficulties.
Sex therapy offers an evidence-based approach to addressing the beliefs, attitudes, anxieties, and context relating to sex and sexuality (Campbell, 2020).Approaches to sex therapy may include psychotherapy approaches, psychoeducation, sensate focus, mindfulness, mirror exercises, communication skills or work with fantasy (Peterson, 2017).
Sex therapy has demonstrated remarkable effectiveness in enhancing sexual health, well-being, and overall quality of life, as supported by numerous studies evaluating its efficacy and comparing it to pharmacological interventions (Abdo et al., 2008;Brotto et al., 2016;Frühauf et al., 2013;McCabe et al., 2008;Van Lankveld et al., 2001).Notably, specific interventions such as sensate focus have yielded significant improvements for individuals with a sexual dysfunction, with 83% of patients reporting an improved sexual experience (Trigwell et al., 2016).Additionally, mindfulness-based psychological interventions and cognitive-behavioral therapy have demonstrated efficacy in treating sexual dysfunctions (Basson et al., 2010;Brotto et al., 2008;Gunst et al., 2019;Van Lankveld et al., 2001).Despite the underutilization of sex therapy services, it is evident that many sexual difficulties respond positively to this form of therapy (Frühauf et al., 2013).
It is hypothesized that numerous individual and systemic barriers pose difficulties in accessing sex therapy services.Although the importance of identifying barriers to treatment for sexual difficulties is generally acknowledged, no study has examined the barriers to help-seeking specifically in relation to sex therapy.
The existing studies primarily investigate barriers to help-seeking for sexual difficulties in the context of a medical provider (Gore-Gorszewska, 2020; Hinchliff et al., 2021;Hinchliff & Gott, 2011;Schaller et al., 2020;Traa et al., 2014).Furthermore, many studies examining help-seeking behaviors for sexual difficulties took place among older adults, which may not be applicable to the wider population (Fileborn et al., 2017;Hinchliff & Gott, 2011;Moreira et al., 2008;Schaller et al., 2020).The decision to engage in sex therapy is understood to be influenced by a myriad of well-accepted, yet non-empirical barriers stemming from psychological and sociocultural factors.A key aspect of these challenges is the sensitive nature of sexuality and the societal stigma associated with sexual difficulties.Other barriers include limited sexual education, inadequate awareness of therapeutic resources, concerns about confidentiality, fear of judgment, and the influence of past negative experiences.Hence, the importance of our research study rests in its pursuit of an empirical examination of these widely-accepted barriers to seeking sex therapy, in order to provide a robust evidence-based understanding of help-seeking behaviors in this context.
Existing studies have identified numerous barriers that potentially account for the low incidence of help-seeking for sexual difficulties within primary care settings.This understanding largely arises from the data of the Global Study of Sexual Attitudes and Behaviors (GSSAB), an international survey of women and men aged 40-80 years across 29 countries (Laumann et al., 2009;Moreira Junior et al., 2005;Moreira et al., 2005Moreira et al., , 2006;;Nicolosi et al., 2005).Findings from the GSSAB within Britain and continental Europe identified the main barriers to seeking help for a sexual problem as 1) not viewing it as serious (71.3% of men and 61.1% of women), 2) a belief that it was normal/being comfortable with things as is (64.2% of men and 58.2% of women), and 3) not viewing a sexual problem as a medical matter (48.6% of men and 46.9% of women) (Moreira et al., 2005).It is unknown whether these results would be applicable to other contexts such as sex therapy.In erectile dysfunction (ED), a sexual dysfunction well-known to be commonly undertreated, the most common barriers to not seeking treatment is the belief that the problem will resolve spontaneously (younger men) and that it was a normal part of aging (older men) (Shabsigh et al., 2004).Interestingly, a qualitative study of older adults in Poland identified that respondents believed only a sexologist could address their sexual difficulties, not a medical provider (Gore-Gorszewska, 2020).These findings indicate the versatility in barriers to help-seeking with a medical provider and highlight how little is known about the barriers and decision-making process involved with seeking a sex therapist.

The Present Study
Due to the lack of research into barriers to seeking sex therapy specifically, the purpose of the present study was to better understand why people may or may not seek sex therapy for their sexual difficulties.A recent study found that many participants had negative attitudes and beliefs about sex therapy, poor understanding of what it would involve, and viewed sex therapy as a last resort (Sever & Vowels, 2023).In the present study, we qualitatively investigate barriers to sex therapy in a sample of adults from three English-speaking developed countries.As applied to other qualitative studies, we use a broad definition of sexual difficulties referring to any physiological or psychological difficulties experienced by an individual or their partner, regardless of meeting diagnostic criteria for sexual dysfunction (Mitchell et al., 2011).The knowledge generated from this study could be valuable to sex therapists, sexual educators, healthcare providers, sex therapy accreditation bodies, and policymakers when planning and implementing interventions and policies to enhance the utilization of sex therapy services.

Study Design and Participants
A total of 30 participants were recruited for the study using quota sampling to ensure heterogeneity with respect to age and gender.Informed consent was gained from all participants and the study was conducted in accordance with Swiss Psychological Society ethical guidelines.Recruitment took place between May and June 2021 through UserTesting.com,an online qualitative data collection platform for new applications and products.Participants were eligible to participate if they were currently engaged in a romantic partnership and if the participant or their partner had a current or previous history of sexual problems, defined as, "issues with your sex life in the past", with no specific timeline stated for the required duration of the sexual problem/s.One participant was excluded due to technical difficulties impacting interview sound quality and two participants were excluded due to difficulties with English.From the final sample of 27 participants included in the study, the mean age was 29.67 years (SD 8.69 years) and 15 (55.6%) were men.A total of six participants (22.2%) resided in Canada, 12 (44.4%) in the United Kingdom and nine (33.3%) in the United States.Relationship status was reported as cohabitating or married in 14 (51.9%) of the participants and as in relationship but living apart in the remaining 13 (48.1%).The median relationship length for participants spanned 24 months.Past sexual issues in the participant, partner, or in both individuals were 29.6%, 14.8%, and 55.6%, respectively.Reporting for this study follows Standards for Reporting Qualitative Research (SRQR) guidelines (O'Brien et al., 2014).

Procedure and Interview Questions
Unmoderated structured interviews (i.e., an interview in which there is no interviewer) were anonymously conducted to explore barriers to seeking sex therapy in response to the questions 1) Have you ever been, or would you ever consider going to sex therapy?, 2) Have you experienced any of the following [sexual difficulties listed], 3) If you've experienced any of these problems, can you tell us more about it?, 4) If you've experienced any of the problems above, did you seek help?, 5) What help did you seek?, 6) If you did not seek help, what stopped you from seeking help?Questions relating to attitudes and beliefs toward the service and about sex therapy being delivered through an alternative platform was deemed outside of the scope of this study and not included in the analysis.The full interview protocol along with all participants' responses can be found on the Open Science Framework: https://osf.io/y6ksx/.Completed interviews were transcribed using artificial intelligence software, and this was later moderated by a research assistant for errors.Participants received $10 directly via UserTesting after completion of the interview.

Positionality statement
The authors of this research are both white, cisgender, heterosexual women, residing in an affluent European country.We are academically trained and practice as sex therapists.Our experiences and identities indubitably shape our approach to this study.Although we possess professional knowledge on the subject matter, our personal backgrounds have granted us the privilege of easier access to healthcare and psychotherapy, potentially influencing our perception of barriers to seeking help.Furthermore, our heterosexual and gender-conforming identities might inherently limit our full understanding of diverse sexual experiences.We recognize these potential biases and have strived to maintain reflexivity throughout the research process, ensuring that our participants' voices remain central to the findings.

Data Analysis
Qualitative interviews were analyzed using reflexive thematic analysis (Braun & Clarke, 2006, 2019) and an inductive approach to coding.Codes were created throughout the coding process by coding each meaning unit which varied in length and frequency.These codes were then refined iteratively until they converged onto the final themes.'[…]' was used in the quotes if unnecessary detail has been removed.Repeated filler words such as 'like' and 'yeah' were excluded to aid the readability of the quotes.All identifying information was removed.

Results
The results are structured around five main themes relating to a) accessibility and cost, b) perceived willingness of a partner to engage, c) psychosocial factors, d) confidence in own abilities, and e) perceived severity of the sexual problem.An overview of the identified themes and examples of supporting narratives are presented in Table 1.While all participants recruited had experienced previous sexual concerns either personally or with a partner, none had accessed a sex therapist, alluding to the presence of barriers impeding the utilization of sex therapy.Rather than accessing a sex therapist, participants sought help through family, friends, the internet, and medical providers.There was often a culmination of inhibitive factors at play, as described by one participant that it was "a combination of things" which made help-seeking for a sexual difficulty challenging.

Accessibility and Cost
Barriers related to access and cost were expressed by several participants.Firstly, the lack of awareness around where to find sex therapy services posed a significant hindrance.For example, "…Just general not knowing, who do I talk to?Do I call my health insurance…how does that work?Where would I find this person?".This led participants to feel that the service was unreachable and difficult to access, likely perpetuated by an overall lack of conversation theme interpreted examples of identified narratives access and costs "i don't know where to go.i would have to Google something, but i also live in a tiny country…" "i wouldn't immediately know where to find information or to contact someone about that sort of thing" "… one of the main things that puts people off is the very high price of sexual therapists" "i would be able to find places to go… i can search up places if i don't have one in mind" Willingness of a partner to engage "But unfortunately, my partner is not a very open person when it comes to introducing other people into our intimate lives.so, i think it would be a bit of a challenge for them" "i didn't want my partner to feel like there was something wrong with him.um i also didn't want to feel like there was something wrong with me…" psychosocial factors "yeah, i guess, all of the above stigma around having these kinds of issues… there was a chunk of time where i wanted to [have sex], and he [partner] didn't and, you know, men are supposed to always want to [have sex].so, i guess there's that stigma that if he doesn't, there's something wrong with you" "haven't felt confident enough to seek help" Confidence in own abilities "i keep thinking i can work it out on my own" "it didn't seem that big a deal.it just seemed something that was easier or would have been easy to solve between us, which was in the end, rather than men thing.that required i guess, professional help.if that makes sense.yes, it just seems more of a very personal thing or very easy.Go have a personal thing that we can resolve between us rather than having to maybe look for outside help" "i just kind of thought maybe this will pass" "…something that would pass like by itself and i would not really need an expert opinion about it" severity of problem "no, i did not seek help.Just because i figured it was a normal kind of problem" "a sex therapist may be better served helping people with more serious issues" "i haven't really tried to get any assistance on those because those aren't really big issues.to me.they're just like, little bumps in the road.i feel like they're pretty normal.""i didn't think that it was serious enough to seek help.if i did, then i would probably first go to the internet and just Google my problems and see what the sort of internet said.and then if i really felt like it was serious and needed more attention, then i would probably contact a professional."Willingness to engage in sex therapy in the future "for me, i would go right would go now", "i don't have anything against going…" and "i would definitely consider going to sex therapy" "…the only reason i would considered actually going is if, you know, my partner thought it was really important" around the promotion of sexual health.While some participants expressed awareness that they should seek help for a sexual difficulty, a general not knowing where to go resulted in a sense of helplessness and inaction.The perception that sex therapy was inaccessible was often described by individuals who stated that they resided in smaller and more remote regions.In addition, there were concerns that there would be high costs associated with sex therapy.One participant stated, "Why would I pay, I don't know like hundreds of pounds, for going to a therapist…?".Sex therapy was thus regarded as requiring a high commitment.Few individuals knew of friends or family or other contacts who had accessed sex therapy services and whose experiences they could draw upon.Ultimately, perceived high costs and a general unawareness about where to find a sex therapist reduced the accessibility and feasibility of accessing sex therapy.

Willingness of Partner to Engage
The perceived willingness of a partner to be open to engaging in sex therapy had repercussions on whether an individual accessed sex therapy services.As sex therapy was overwhelmingly considered a couple's activity based on participant dialogues, partner engagement was considered highly important and a sign of support.It appeared that one partner generally led the help-seeking process and a reluctance in the other partner to engage in sex therapy reduced overall help-seeking behaviors.For example, on participant stated, "…I also don't know if my partner would want to do that" and "I would go…if my partner would be comfortable with it".A partner's prior openness to discussing sex and sexuality was considered a relevant marker of their willingness to engage in the service.Overall, the perceived willingness of a partner to engage in the service had significant implications for help-seeking behaviors.

Psychosocial Factors
Psychosocial factors were cited by participants as substantial barriers to help-seeking.Psychosocial factors included experiences of embarrassment, shame, and stigma.One participant stated, "I'm probably embarrassed, because I don't like to talk about my sexual issues, if I do have any at that moment".Fear of these negative experiences significantly reduced participants' willingness to engage in help-seeking.Another participant stated the clear importance of minimizing these negative experiences, "…not having it as something that's going to go down in your medical record, for something that you know, you might be embarrassed about".Privacy and remaining discrete were crucial aspects to reducing shame, embarrassment, and saving face.The stigma surrounding sex therapy was highly pervasive and represented a collective barrier to sex therapy.This was evident in the statement, "I think the stigma part is still there.I mean, you don't want to…admit anything that has to do with… the type of performance you want to be known for" and "…I wasn't even able to talk to friends".It appeared that going to sex therapy implied that there was something inherently "wrong" with you and had negative connotations for one's own sexual performance.

Confidence in Own Abilities
Many participants expressed that they felt their sexual concerns could be self-resolved either individually or within their union, rather than seeking a professional.This was evident in the statements, "It just seemed something that was easier or could have been easy to solve between us…" and "I feel like a lot of people want to accomplish it on their own and never look to someone to talk to…".This confidence and sense of agency in one's own abilities to resolve a sexual concern reduced help-seeking behaviors and was particularly present amongst male participants, "I'm the type of guy to fix things on my own…".Additionally, there was a strong sense that sexual difficulties would pass with time and that often no intervention would be required.For example, "I just kind of thought maybe this will pass".This highlights a dismissive attitude toward sexual difficulties and wellbeing.

Perceived Severity of the Sexual Problem
A perception that sexual concerns were not 'severe' health problems further deterred help-seeking behaviors.This differed from the confidence held in one's abilities to resolve a sexual difficulty, as participants often didn't view their sexual difficulties as severe enough to warrant intervention or treatment.For example, "It didn't seem that big a deal" and "I haven't considered it because…well, if my parents could overcome their problems, and if the whole world can overcome their problems, why should I go there?".Participants often doubted the need for sex therapy and questioned whether the severity of their problem justified accessing the service.Sexual difficulties were regarded as severe if they had progressed to the point of a relationship deteriorating or divorce.Others expressed that they felt their problems were normal or just "bumps in the road", implying a normalization of sexual concerns.While this may indicate a lack of awareness around the implications of sexual difficulties, it may also signify, more importantly, that individuals are unaware of the repercussions presented by sexual difficulties.This was expressed by one participant, "…it seems something really minor to have to go and get help for.I know I'm just perhaps overthinking a little bit.But perhaps it's something that isn't as minor as I think, and it would you be useful to get help for?"The undercurrents of this statement indicate that sexual difficulties may be substantially more impactful than initially realized.Other participants, conversely, felt that help should be sought for sexual difficulties, regardless of the severity."I think, personally, that if it's something that you want to talk to somebody professional about, then you should go regardless of whether or not you know it's affecting your life in a serious way…".

Remaining Open to Future Engagement with Sex Therapy
Participants were asked about their willingness to consider sex therapy in the future, in addition to the themes explored above.Despite the multiple barriers impacting help-seeking behaviors and utilization of sex therapy, many participants affirmed that they would not hesitate to access a sex therapist in the future if necessary.This intention was encapsulated in the statement, "I mean, yes, I would consider going…it's the same as any kind of therapy…".The most common conditions for future engagement were a deteriorating relationship or if a partner deemed it important.Yet, other participants expressed doubts about the utility of the service, indicating they were unlikely to use it in the future, as evidenced by one participant stating, "Honestly, I feel as if I can figure out my situation without having to talk to someone…".Interestingly, men in the study were more inclined to consider engaging with a sex therapist in the future, contrasting with women who were less likely to view sex therapy as an appropriate option for addressing sexual difficulties.

Discussion
Gaining an understanding of barriers to sex therapy is crucial to reducing obstacles to care and promoting sexual health and wellbeing.The results of this study provide new insights into why individuals with sexual difficulties might not seek help from a sex therapist.Common help-seeking behaviors included family, friends, the internet, and medical providers, which was consistent with findings from other studies on self-reported sexual difficulties (Hobbs et al., 2019;Moreira et al., 2005Moreira et al., , 2008)).These sources, however, may not always be accurate or sufficient for sexual difficulties (Bagherzadeh et al., 2010).Overall, none of the participants or their partners had previously seen a sex therapist.This confirmed previous research that a significant proportion of people with sexual difficulties do not seek treatment (Dunn et al., 1998;Gott & Hinchliff, 2003.In our study, there was a discordance between the participants who reported that they would like to receive help for sexual difficulties and actual help-seeking behaviors.This was observed in an earlier study on sexual help-seeking, which identified that while 52% reported that they would like to receive help for a problem, only 10% of these participants followed through with the behavior (Dunn et al., 1998).One potential explanation for this discrepancy could be the level of distress concerning the sexual difficulty.The distress experienced might not have reached a critical threshold necessary to overcome barriers to seeking sex therapy.Overall, the participants spoke about five types of barriers to seeking sex therapy: accessibility and cost, perceived willingness of a partner to engage, psychosocial factors, confidence in own abilities, and perceived severity of the sexual problem.Although earlier studies had identified barriers relevant to help-seeking with a medical provider, many of these, such as not believing that a sexual difficulty was a medical problem, that a doctor could help, and overall discomfort discussing sexual concerns with a doctor (Moreira et al., 2005) were not found to be relevant to the sex therapy context.Barriers that were consistent with past studies related to stigma and embarrassment, costs, not thinking a sexual problem was serious, and believing that the problem was normal (Moreira et al., 2005;Porst et al., 2007;Rade et al., 2018).This suggests a diverse range of experiences and perspectives among individuals, reinforcing the multifaceted and complex nature of the barriers to seeking sex therapy.
There were several barriers relating to access and cost, which have previously been reported in many studies (Adegunloye & Ezeoke, 2011;Moreira et al., 2005).The low levels of help-seeking reflected the poor awareness of the availability of specialty services and treatment for sexual difficulties (Mercer et al., 2003).A general lack of awareness regarding where to find sex therapy services resulted in the sex therapy service appearing unreachable and difficult to access.Additionally, a sense of not knowing where to go contributed to a sense of helplessness.The perceived inaccessibility of the service was likely perpetrated by an overall lack of conversation around sexual well-being and others concealing their own experiences with sexual difficulties/help-seeking. Concerns regarding accessibility appeared more acutely in individuals residing in smaller and more remote regions, consistent with previous findings on help-seeking (Jackson et al., 2007).There were also concerns that sex therapy would require a high financial commitment.Currently, rebates and access to bulk billing vary between sex therapists based on their primary profession, although many are considered an out-of-pocket expense (Ramanathan & Redelman, 2020).This reduced the appeal of the service.
The willingness of a partner to be open to engaging in sex therapy had repercussions on whether an individual accessed the service.This perceived willingness to take part in the sex therapy process was viewed as a reflection of a partner's commitment to resolving the sexual difficulty.A reluctance in one partner had the ability to reduce overall help-seeking behaviors.As sex therapy was overwhelmingly considered a couple's activity in previous research using the same dataset (Sever & Vowels, 2023), partner engagement was considered highly important.Other previous studies have also highlighted that a partner's engagement in therapy was a vital aspect of successful therapeutic outcomes (Vowels, 2023).
Psychosocial factors, including experiences of embarrassment, shame, and stigma were highly pervasive and represented collective barriers to sex therapy.Utilizing sex therapy services was associated with a connotation that there was something "wrong" with an individual and their sexual performance.These experiences are likely associated with negative societal attitudes and beliefs toward sex and sexuality.The finding was consistent with a study of older adults who reported feeling embarrassed or ashamed when initiating help-seeking about sex related topics (Fileborn et al., 2017).Indeed, participants reported that fears of embarrassment, stigma, and shame could be minimized through privacy and handling sexual difficulties in a discrete manner.Experiences of shame may be perpetuated by discomfort from medical providers, who infrequently ask patients about sexual health during routine consultations (Moreira et al., 2005(Moreira et al., , 2008)).Furthermore, many clinicians feel underqualified to treat sexual difficulties (Humphery & Nazareth, 2001), highlighting the role of referral or a collaborative approach to managing sexual difficulties alongside sex therapists (Ramanathan & Redelman, 2020).
A preference for and confidence in participants' own abilities to self-resolve sexual difficulties deterred sex therapy help-seeking behaviors.This was consistent with the established stages of the help-seeking process, which generally originates with self-identifying a problem and attempting self-help (Catania et al., 1990).Among individuals with sexual difficulties, around 80% seek informal/self-help (van Lankveld, 2009).It is only in the later stages that the help seeker turns to a specialist professional such as a sex therapist (Catania et al., 1990).This was observed in another qualitative study of help-seeking for sexual difficulties within a group of older adults that identified that participants would prefer not to seek help immediately for a sexual problem, but rather to identify the cause and cure, make changes and wait to see if the problem resolved (Hinchliff et al., 2021).This preference to self-manage health concerns appears widespread, with another study identifying a preference to self-manage mental health problems as the most common reason for avoiding treatment (van Beljouw et al., 2010).While a self-help approach was an important aspect of the help-seeking process, finding and receiving accurate help despite the high volume of misinformation relating to sex and sexuality may result in unhelpful and unsuccessful strategies (van Lankveld, 2009).A belief that a sexual concern will resolve could further suggest a dismissive attitude toward sexual well-being or a lack of understanding of the potential burden associated with untreated sexual difficulties.Nevertheless, care providers can still promote sexual well-being with this viewpoint by promoting the empowerment and self-sufficiency of patients.
There was a clear perception that sexual concerns were not 'severe' health problems.As a result, the need for sex therapy was often questioned.Similarly, previous studies have established that not considering a sexual problem as severe was a common belief and deterred individuals from disclosing and discussing their sexual difficulties (Andrade et al., 2014;Moreira Junior et al., 2005;van Beljouw et al., 2010).Azar et al. (2013) highlighted that a symptom does not necessarily trigger help-seeking, rather it is triggered by the interpretation of the symptom being sufficiently severe (Azar et al., 2013).This reflects a desire to be normative.Feelings of shame, embarrassment and stigma may contribute to minimizing the seriousness of sexual difficulties (Gore-Gorszewska, 2020).This highlights an important barrier to seeking sex therapy.A sexual difficulty was considered severe if it had progressed to the point of a relationship deteriorating or divorce.It has been previously hypothesized that individuals in longer-term relationships may wait longer to seek help as they feel they have plenty of time available (Hinchliff et al., 2021).Many participants expressed that they felt their sexual difficulties were normal, implying a normalization of sexual concerns (Ibine et al., 2020).This was consistent with another study of women with endometriosis and sexual pain, which identified beliefs that sexual pain was normal which contributed as barriers to help-seeking (Nimbi et al., 2020).Alternatively, perhaps a low perceived severity may indicate that individuals do not view their sexual difficulties as problematic (Hinchliff et al., 2009).It is important to consider that sexual well-being is weighted differently by each individual (Ramanathan & Redelman, 2020).For example, a population-based survey identified that while hypoactive desire was present in one-third of men and over half of women, it was only experienced as causing significant distress in around 20% (Briken et al., 2020).It is certainly plausible, however, that sexual difficulties perceived as low severity may contribute to repercussions on well-being, including individual and relational implications.This was evident in one participant's statement, who despite describing their sexual difficulty as minor, expressed undercurrents that it was detrimental and that they should seek help.
Overall, multiple barriers clearly altered help-seeking behaviors and impacted the utilization of sex therapy.However, despite identifying these barriers, many participants remained adamant that they would be open to accessing a sex therapist in the future.This highlights a discourse between intention and behavior.Reasons for future engagement included if a relationship deteriorated and if a partner thought it was important.Surprisingly, men were more likely to be open to engaging with a sex therapist than their female counterparts.This finding contrasted prior research on psychological treatments which generally find that men seek psychological treatment less often than women (Parent et al., 2018;Sagar-Ouriaghli et al., 2019).Research by Moreira et al. (2008), however, identified that men (26.0%) were more likely to seek help for their sexual problems than women (16.7%).It is possible that men may be more inclined to seek a sex therapist as they associate sexual difficulties with higher levels of distress or that men's sexuality is more highly associated with performance and masculinity (Potts, 2000).Indeed, previous research has found that greater sexual distress was associated with help-seeking behaviors (Hendrickx et al., 2016).Nevertheless, most people do not seek help for their sexual difficulties, even when distressed by the problem.

Implications
To our knowledge, this was the first study to explore barriers to help-seeking specifically for sex therapy.The study provides new insights into the limited evidence base in this area.It is crucial to better understand delayed help-seeking for sexual difficulties, which can be associated with an increased risk of depression, poor sexual confidence and self-esteem, impaired quality of life and interpersonal difficulties (Balon, 2017;Heiman, 2002).Clearly, identifying and mitigating potential barriers to help-seeking is an essential aspect of improving access to care services and promoting overall health and sexual well-being.While many previously identified barriers to help-seeking for sexual difficulties were specific to medical providers, such as not believing that a sexual difficulty is a medical issue, sex therapy represents an effective and alternate specialist service for the management of sexual concerns.While some sexual difficulties may resolve on their own or through self-help methods, it is important for the public to feel that specialized services such as sex therapy are available with minimal difficulty.Healthcare providers require comprehensive training and education in sexual health to feel confident openly discussing sexual difficulties and referring them to specialist services like sex therapy when necessary.In regard to the cost barriers, policy makers should consider strategies to ensure the affordability of sex therapy, such as incorporating it into broader healthcare coverage, working toward sliding scale fees or subsidized therapy sessions.The study findings additionally suggest that increased education and public awareness about sex therapy could address a significant portion of the identified barriers.Clear communication about the role and scope of sex therapy, perhaps through public dialogues, and media portrayals that normalize help-seeking for sexual difficulties and reduce barriers that might deter individuals from seeking help.This study illuminates the various obstacles individuals face when considering sex therapy services, providing an imperative foundation for the development of targeted educational initiatives and strategies.By understanding and addressing these barriers, we can foster more timely help-seeking behaviors, ultimately enhancing sexual health and overall well-being.

Limitations and Future Research
This study should be considered within the context of its limitations.While the unmoderated interviews presented certain advantages such as ensuring anonymity and reducing social desirability and stigma, we were unable to record non-verbal cues and behaviors from participants, which may have influenced the context in which the dialogue was interpreted.An important consideration in interpreting our results is that all participants agreed to take part in a study about sex therapy, which may be a positive marker for help-seeking tendencies.Half of the participants also reported not living together.We did not observe differences in the barriers between the participants who lived together and those who did not, but it would be interesting to examine whether living situation might affect potential barriers to seeking sex therapy.Despite the variances observed in participant dialogues, our sample represented participants who had chosen to take part in an online platform testing new applications and products and represents relatively young individuals from western countries, potentially limiting this study's generalizability to other contexts.
Moreover, we did not collect data on whether participants identified as transgender or what their sexual identity was, which hinders a comprehensive understanding of the representation of diversity among the sample.Future research should aim to gain an understanding of difficulties for minority groups to access a sex therapist and establish how to overcome identified barriers.Additionally, it could explore alternate sex therapy methods that reduce established barriers such as online therapies (Vowels, in press).Finally, the study included participants from three countries (USA, Canada, and UK).These three countries have different healthcare systems and thus potential barriers to accessing treatments in terms of cost and accessibility may differ not only between regions but between the three countries.The differences were not evident from the interviews, but it may be interesting in future research to compare potential barriers between countries.

Conclusion
In conclusion, this study provided insight into barriers to sex therapy in individuals who had previously experienced sexual problems either themselves or with a partner.We identified five general themes, that highlighted the difficulties in seeking help and gaining treatment for sexual difficulties.This was the first study to explore barriers to help-seeking in the context of sex therapy.The findings indicate the barriers that impede care for sexual difficulties and highlight the need for further promotion of sexual help seeking and treatment.

Table 1 .
overview of themes and examples identified in participant narratives.