As my colleague Dr. Steve Levine has put it, “Sex is not simple.”

“Sex” and sexiness are used to sell everything in American society. We are bombarded with so many simplistic images and platitudes about “good sex,” masculinity, and beauty that many of us feel insecure about whether we’re good enough (whatever that means), sexually or in general, to measure up.

I recently had a middle-age patient tell me, “Sex is only for really good-looking people.”

I’m afraid that many people feel this way. It’s hard to escape from being bombarded by photos of gorgeous male and female models who are actually photoshopped to make them look even more handsome or gorgeous.

The irony of this middle-age woman telling me this is that (a) She was quite attractive and kept herself in good shape with exercise and good eating, and (b) her spouse thought she was tremendously attractive — as she was.

But she had a terrible time feeling desirable. Internally, she was full of comparisons with models and actresses four decades younger than her. She had such contempt for herself and her imagined inadequacies that she couldn’t imagine herself in bed with her partner.

She couldn’t even imagine herself naked, allowing the simple pleasure of two naked bodies together.

It’s terribly hard to have a healthy relationship with your own sexuality or with a partner if you have low self-esteem.

The dictionary defines self-esteem as “confidence in one’s own worth or abilities.” You can also think of it as self-respect or self-love.

The building blocks of your self-esteem came from how you were treated in your family. If your parents acted respectful of your thoughts and feelings, if they treated your physical needs and your body with care, your self-esteem probably has a good foundation.

It’s not that parents have to always give you what you want. In many cases, that would just turn you into a brat. But you need to have been seen and heard in order to feel that you deserve to be seen and heard.

I worry for younger generations because the tendency to have to post every perfect photo on Instagram, Facebook, and Snapchat spells trouble. There is evidence that intense internet usage contributes to mounting rates of anxiety and depression. And many adults look to social media to boost their self-esteem as well.

Self-esteem is critical to healthy sexual development. That’s why it is one of the first milestones in my Milestones of Sexual Development model.

Consider the central role that having good self-esteem will have in healthy sexuality. Here are a few examples:

● Good self-esteem can buffer you against the demand that you look perfect at age 20, or like you are 25 years old when you reach the ripe old age of 60 and your body begins to show the signs of age.

● Good sex depends on asking for what you want. What happens if you never were allowed to express your desires growing up?

● Poor self-esteem makes it difficult to feel safe and deserving asking for the time you need to get enough stimulation to come to orgasm.

● How can you feel confident enough to stop someone from making you do sex acts that you don’t want to do if you feel worthless and unlovable?

Pay attention to whether your ability to enjoy your sexuality is hampered by feelings of low self-esteem. Besides reading some excellent self-help books, like the one by Dr. Nathaniel Brandon, you might also consider this quote from Albert Einstein:

“Everybody is a genius. But if you judge a fish by its ability to climb a tree, it will live its whole life believing that it is stupid.”