Let's Talk About Sex and Body Image! Meet Sex Therapist Dr. Nicole Van Ness, LMFT

Have you been struggling with your body image so much that it has been affecting your sex life? Is your partner complaining that you don’t want to have sex that frequently, and you feel hesitant to share that it’s because you feel uncomfortable in your own skin? Whether you live in San Diego or elsewhere, you likely know that having a regular and fulfilling sex life is important for intimate relationships. The reality is that A LOT of people struggle with sexual intimacy, and when you have an eating disorder and feel negatively about your body, it becomes a drain on your life and relationships.

Needing answers? I have brought top expert, as well as friend and former top doctoral student of mine, Dr. Nicole Van Ness. Nicole went to school at Alliant International University and learned her trade as a sex therapist in San Diego, and in recent years she has moved to Texas, where she has a private practice and is adjunct faculty at Southern Methodist University. Nicole has maintained her California license as a marriage and family therapist, and she provides videoconference services for individuals and couples in San Diego and other parts of California.

How long have you been a sex therapist in San Diego and in Texas?

I’ve been practicing individual, couple, and family therapy since 2008, and I started specializing in sexuality in 2010.  I always knew I wanted to do this work, and I was fortunate to receive extensive training and supervision from some amazing practitioners in different areas (therapy, medicine, etc.).  I started in private practice in 2010, got fully licensed in 2015 in California, then in 2016 in Texas as a state board approved MFT supervisor.  

What does being a sex therapist mean?  

I get asked this question a lot.  I think people have some funny misconceptions about sex therapy.  When I first told my mom I was going to do this work, for example, she freaked out – she thought I was going to be having sex with people for a living.  I got a good laugh, and told her I’m not going to be a sex worker (I’ve got nothing against the folks in that line of work, it’s just not for me.  Plus, a discussion of sex work is outside the scope of this interview 😊).   

First of all, being a sex therapist is a privilege.  Sex is a deeply personal and private part of most people’s lives, so clients’ willingness to share it with me is something for which I have a deep respect and appreciation.   Second, being a sex therapist is like being any other kind of therapist.  There are therapists who specialize in depression, anxiety, personality disorders, addictions, eating disorders, obsessive compulsive disorder (OCD), autism, and so on.  Some of us specialize in sex, and some of us specialize further into particular domains of sexuality, such as gender-related issues, trauma/abuse, religion and sexuality, or specific dysfunctions.  The interesting thing is that we also must have a good deal of knowledge in many areas outside of our specialization, too, which was something I was a bit surprised to learn early on.  

Most clients who have difficulties with sexuality also have difficulties in other areas; they also often are not aware of the connection between, for example, their sexual dysfunction and their depression, or their OCD, or their alcohol abuse, and so on.  I never know who will walk into my office, and what constellation of symptoms and experiences they will bring with them when they present for sex therapy.  It then becomes my job to do a full scale assessment and triage what items need to be treated first, so that we can safely and effectively explore the complex interplay between mental health, culture, religion, experience, and sexuality to address what they came in for – improving their sex life.  The first phone call often sounds simple at first, but there are many layers to uncover. 

Sexuality can be such a BIG issue for people recovering from eating disorders.  So much of it has to do with body image.  Can you talk a little about the intersection between how people see their bodies and how they feel about sex?

Yes!  Oh my goodness, body image is significant in my work.  I’m going to digress a tiny bit to make a point here.  My former supervisor used to say “sex is adults at play.”  When we consider small children, for example, playing on a playground, we imagine them running, jumping, laughing; we might see unrestrained laughter, vigorous physical activity, spontaneous movement, back-and-forth turn-taking, quiet interactions, or rambunctious and boisterous ones.  The point is, at play, little kids aren’t worrying what others think, what they look like, whether they’re being too loud, or “too much.”  They’re just purely in the moment.  Now come to adult play – how many of us can fully let loose like this and enjoy being in our bodies?  

Sex educator and author Emily Nagoski says that pleasure is the measure of a successful sexual encounter.  In order to experience pleasure, we need to be in our bodies, and allow ourselves to receive attention, affection, touch, appreciation, and pleasure.  We need to be a little bit selfish (not in a mean way, though) and feel deserving of pleasure.  Many people struggle with all of these things.  When you add the additional layer of an eating disorder, there comes added complexity and barriers to embodied, pleasure-focused, present-minded “play” involving your full body.  

There are two specific phenomena in sex therapy that come to mind regarding body image – the first called spectatoring and the second is anxious self-consciousness.  Spectatoring (introduced by groundbreaking sex researchers Masters and Johnson) is when people experience sex from a third-person point of view, rather than being fully present in their bodies.  Thoughts like, “am I doing this right?” “what do I look like?” “can they see my double chin?” “geez, I’m probably really messing this up right now” and so on happen during spectatoring.  Anxious self consciousness (described by Wiederman & Sarin, 2014) is an aspect of body image that most affects sexual functioning.  

It is interesting that overall body image is not nearly as predictive of sexual satisfaction as one might think.  It tends to be body image difficulties specifically related to the bedroom (e.g., physical attractiveness, breasts, and genitals) that play a bigger role.  This is where anxious self-consciousness comes in.  Similar to spectatoring, when you’re worried about the size of your breasts or genitals, the odor or amount of hair on your genitals, or your overall sexual/physical attractiveness, it’s hard to relax into your body and into pleasure.  When you add the experiences of various eating disorders, there may be additional complexities to unpack.

I’m curious whether how much of the work you do has to do with the mechanics of sex and how much of it has to do with addressing how people feeling dissatisfied with their bodies.

I’d say the breakdown is approximately 20% mechanics, 20% body image, 20% overall confidence, 20% relationship dynamics, and 20% other (trauma history being a big one, but also sexual pain, physical conditions, other mental health challenges, medications, aging, etc.).  It isn’t an exact breakdown for every single client, and there is often overlap, but these are the main contributors.

How do you address when a client’s partner/spouse feels dissatisfied with their body?

That’s is a tough one.  It depends on a lot of things – whether they ever were attracted to their partner matters.  If they were, it’s a little easier to get back; if not, it’s tougher to create something from nothing.  When it comes to the chemistry of attraction, sometimes it’s just there or it isn’t.  Other times though, there are tangible things a person can do to increase their attractiveness, and it often starts with basic hygiene and self care.  I tell people, “don’t ever stop trying to impress your partner.”  You don’t need to be a perfectionist about it, but brush your teeth, wear clean underwear and nice clothes, spray on a little perfume/cologne – make an effort.  Plus, you’ll feel better about yourself, and confidence (not to be confused with arrogance) is one of the biggest turn-ons for a LOT of people!  Also, the person’s cognitive flexibility is a big deal.   When people are very rigid in their thinking patterns, change is slow and difficult.  When people are more flexible, however, we can work towards different definitions of “attraction,” introducing new experiences, and expanding their repertoire.  

I know that there is a huge biological component that goes into training to be a sex therapist.  What is important for people to know about how sex therapists address biological functioning?

Every therapist is different, and not every sex therapist goes into the same level of detail about biology.  Just like therapists who specialize in depression, some use cognitive approaches, some use more emotional approaches, some are more existential, and some focus on biology (neurofeedback, biofeedback, medications, etc.).  It’s the same idea for sex therapists – some of us are more cognitive, some are more emotion-focused/experiential, some more biological.  I’m an over-achiever and try to integrate all of these things (I don’t see sex operating without all of them).  Some sexual difficulties are more biological, and therefore cannot be treated effectively without this consideration, but others are less so.  There’s no right or wrong way for every client or therapist, it’s about the specific client issue and a goodness of fit between client and therapist.  

What kind of work do you do around body image and sexuality?

I definitely explore body image with clients when it comes up (it doesn’t always, but it often does).  I have some activities that I do involving exploring gendered messages about body type stereotypes across history (showing and discussing videos, deconstructing media images, etc.); mindfulness meditations increasing awareness and comfort with the body; self-exploration activities at home that involve in-depth looking and labeling and appreciating different parts of the body; and education in-office about different body parts using diagrams and puppets.  I find that the more exposure and practice people get with their own bodies, the easier it gets over time to relax into their bodies.  Of course, this work is a bit different with my eating disorder clients, because there’s that added layer, so that work tends to be a bit more focused and prolonged.

What can people expect in a first appointment with you?

People are usually pretty anxious about their first therapy appointment, so I try my best to de-escalate any tensions by prioritizing connecting with and getting to know my clients.  Coming from a feminist perspective, I use a fair amount of transparency and self-disclosure (appropriately, of course), as well as humor, to join and build rapport.  I like to find out people’s interests, their strengths as an individual or couple, what makes them unique, as well as the challenges that are bringing them to therapy.  I review policies, confidentiality, consent, etc. as well.  I like to ask about people’s expectations for therapy, what their fears/concerns are, and what they hope to accomplish.  I actually find the miracle question super helpful and will often use that.  

One of the first things I assess for is cognitive and affective flexibility – can the person shift their emotional states relatively easily, or do they get fixated or stuck in rumination?  Is the person open to re-evaluate some of their beliefs/misconceptions, or are they more rigid in their thinking?  This helps me to gage the therapeutic process and get at least some idea of prognosis and treatment directions.  I often provide a bit of education, especially if clients are presenting information that shows me they’ve been misinformed.  I will often recommend a book for them to purchase and start reading as an adjunct to therapy, and the titles vary depending on the client.  

Overall, what would you like people to know about sex therapy?

It’s just like any other therapy, but we specialize in sexuality.  Sex may not be the sole topic of every conversation, but we will attend to sexuality ways that other therapists may not be trained or comfortable doing.  Also, sex therapists don’t watch, we don’t touch, and we don’t force you to do or discuss anything you’re not ready to do or discuss.  As with any therapy, you’re going to be faced with choices about change – in order for true change to occur, you need to either change your behavior, or change your value/belief about a situation.  If you’re not willing to examine and make changes in either of those areas, then therapeutic growth/change is unlikely to occur. 

When we’re talking about changing values and/or behaviors in the context of sexuality, people understandably get nervous, because what often comes to mind is their religious values.  People often see sex and religion as opposing realms, and so religious clients often experience internal conflict about seeking sex therapy.  Sex therapy is not about changing or foregoing or sacrificing your religious values.  Having a healthy and fulfilling sex life can very much align with religious values, and sex therapy can be a place to help you bring those two important parts of your life into alignment, rather than in continuous conflict.  Finally, sex therapy can a fun and fulfilling process, in which you get more in touch with your body, with yourself, with your partner, with learning to allow yourself to experience pleasure, and with learning to let go of painful shame.

How can people find out more about you and contact you?

You can find out more about me on my website: www.connected-couples.com, or by giving me a call at 858-356-7444 or email and connectedcouples1@gmail.com

Would you mind sharing one fun fact about you that not many people know?

I almost always win at rock-paper-scissors, like 90-ish% of the time. I don’t know how I do it, but I do. I once had a friend challenge me to a duel – he bet me a dollar for every round we played.  I think we went 31 times, and I went home with an extra $28 in my pocket 😊

 That’s awesome. Can I bet on you next??? Thanks again for talking about sex and body image!


Hey everyone, I really appreciate you reading my blog!  Have a wonderful day. :)  


If you are struggling to find eating disorder treatment in San Diego, give me a call for your free 15-minute phone consultation at (858) 699-3754, and I will help you get where you need to be! 

You can find more information about me on Instagram @drmariannemiller or on my Facebook page