Sex and Therapy 1/6: Talking with Clients about Sex

As a psychosexual therapist, trainer and supervisor, the big issue I encounter is therapists working beyond their competency with sexual issues. On the other hand, I also find that many therapists remain squeamish about discussing sexual issues, which they fear clients will find intrusive.  

In this blog series, I want to share information about the range of sexual issues that all therapists may encounter, and how to proceed depending on level of expertise. This will include discussion of when to refer to a qualified sex therapist, and how UK sex therapists work.

But I will begin this week by looking at the many reasons why it’s helpful to talk to all clients about sex and sexuality.

Since relationships and sex are often at the heart of clients’ problems, or their issues may be affecting sex and relationships, they may expect their therapist to ask about this but be afraid to bring it up themselves if the therapist doesn’t. How people feel about sex and express their sexuality can have a major impact on their sense of identity as well as how they feel about their relationship(s). Indeed, clients who show no improvement despite positive interventions and apparently fruitful therapeutic conversations may have failed to reveal that their major concern is sexual.

Many younger clients, for instance, who present with anxiety or depression, can have difficulty settling into their sexual skin. Their major issue may be confusion about how to behave in, or approach, relationships. More dating issues seem to be emerging in therapy, particularly for those who would like a relationship but consider themselves badly treated by partners or feel uncomfortable becoming too close. Many more have dilemmas such as whether, when and how to tell partners about previous sexual abuse, terminations, or sexually acquired infections such as herpes, which can sometimes be transmitted many years after exposure.

Pornography affects some young people who may expect their own sexual experiences and bodies should mirror some of the unrealistic images they see on screen. Any age group may be using sexual acting out or excessive pornography as their main way of managing their mood, which can sometimes lead to problems including work and relationship difficulties.

Others experience guilt or shame about their sexual behaviour, or lack of it, or even just their sexual thoughts, which may then lead to depression and even self-harm.

Sexual diversity of any kind may be another source of shame that can prevent clients from discussing struggles with coming out or their sexual interests. As well as considering how to come out at all, some clients are grappling with how to tell partners, or their children, that they identify as, say, gay, trans or asexual. It also isn’t safe to assume that individuals identify as they appear in their primary couple relationship. For instance, bisexuality, polyamory and asexuality may be invisible, so therapists need to ask clients how they identify.

Some therapists assume behaviours like kink and non-monogamy are inevitably pathological when this is actually no more likely than with any other presentation. In fact, those with diverse identities may have given more thought to their psychology, sexuality and behaviour than cisgender straight individuals who have never found such reflection necessary.

Those resuming dating after a long relationship may lack sexual confidence or be nervous about how to navigate issues like consent and safer sex, especially if they’re post-menopausal or have been sterilised and don’t consider using condoms applies to them. Such clients may need practical advice and signposting to helpful information or services.

Unfortunately, some therapists feel unprepared for the above kinds of conversations, worrying about making mistakes or causing offence. Even those who do discuss sexual issues may feel unsure about whether this is helpful or when they should refer.

This series will provide relevant advice about how to talk usefully about sex, when and who to involve when necessary and how to recognise the difference between a sexual dysfunction – such as early ejaculation, pain or erectile difficulty, which needs specialist treatment – and a common issue they can tackle themselves. Next week, we will look at assessment and referral.