Sex and Therapy 2/6: Assessment and Referral

Though all therapists can have helpful conversations with their clients around sex and relationships, the ‘sexual dysfunctions’ described in the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) require more specialist qualifications and experience. The dysfunctions fall into the categories of pain, problems with orgasm, diminished sexual interest or aversion and arousal/erectile issues.

Psychosexual therapists work in a variety of ways but will be familiar with the DSM dysfunctions, whether they’re psychological in origin or whether psychological consequences remain when they’ve been treated. Many have specialist interests in particular dysfunctions and may also have additional training in relevant fields such as fertility, relationship therapy or trauma. Finding the right fit is much easier now that more therapists are offering online therapy, and many are registered with the College of Sexual and Relationship Therapists (COSRT) or British Society of Sexual Medicine (BSSM).

As it’s wise to rule out organic causes, initially advising clients to consult their GP is sensible. Some conditions are more likely to be related to sexual problems, including cardiovascular disease, diabetes, neurological and endocrine conditions, prostate disease and obesity. Indeed, sexual problems can be the first indicator of some conditions.

Some sex therapists are medically qualified and able to examine, order investigations, treat and refer appropriately. Some medical departments also have sex therapists attached or collaborate with local sex therapists to provide a joined up service. It’s worth investigating what’s available in your area so you can advise clients appropriately.

Erectile problems which occur only with a partner, and not when the person is masturbating, are more likely to be psychological in origin. Unless they’re ejaculating before penetration or within the first few thrusts, many people’s complaints about how long they can ‘last’ are related to unrealistic expectations. SSRI antidepressants and local anaesthetics may help to slow them down, but psychoeducation may also be needed.

For these – and, indeed, all clients – referral to sex therapy can reaffirm them as sexual beings. However, some clients feel such shame about needing sex therapy that this may need to be addressed first. Some clients choose individual or relationship therapy rather than sex therapy because they don’t actually want to be sexual, but feel they ought to be. It’s consequently important to establish what they hope to achieve and why they’re seeking therapy at this time.

When deciding whether or when to refer on, consider what you’re able to do in relation to the clients’ main hopes for the therapy even when the issues are not DSM related. You may feel confident about discussing sexuality with a young person who’s thinking about coming out as gay or trans, for instance, but could you also at least put them in touch with specialist LGBT+ services, such as Pink Therapy, or a support group?

Clients who are developing sexual dependency, using pornography or sexual acting out as mood management, can be referred to specialist therapists, especially those offering trauma rather than addiction treatment, via COSRT or the Association for the Treatment of Sexual Addiction and Compulsivity (ATSAC), and there are 12 step groups such as Sex Addicts Anonymous. Clients who are offending can be referred to services such as StopSo UK.

Therapists working with couples also need to be experienced in working with safeguarding and domestic abuse, as coercive control can be particularly subtle and may not be recognised by the victim. However, where couples seem to have a stable relationship but sex has dwindled due to circumstances such as tiredness and lack of time, sex positive conversations may be all that’s needed. Next week, we will look at common couple dynamics with a sexual focus in more detail.