What You Miss When You Don’t Ask Your Clients About Sex

It’s the little things.

The little twinge of pain that she ignores because “I thought sex was supposed to hurt.”

The silent “no” that one partner swallows because “It has been a while, and she must be getting frustrated with me…”

Even more subtle than that–the small missed opportunities, the moments of potential connection that are lost because both partners are so focused on putting on a performance of what they think good sex should look like that they don’t stop to actually experience the pleasure of being with one another in the moment.

Little things like this are so common they feel normal, and they just keep happening until someone decides to discuss sex openly with someone who can help. Over time, the little things build up, gradually turning into a whole host of growing and entwined problems.

That swallowed “no” can swell to become a vicious cycle of growing resentment. The missed opportunities can pile up until they amount to a relationship that feels hollow and devoid of real intimacy.

When it comes to sex, our culture’s sense of “normal” is deeply broken. Sex is a taboo topic; discussing it openly can feel shameful, uncomfortable, and embarrassing. Because of this, clients are unlikely to bring it up on their own, to therapists, physicians, friends, or anyone. Many clients don’t even discuss it with their partners. Few therapists or physicians ask about sex. And of course, this silence can easily result in a pile-up of medical, emotional, and relational issues that started as tiny sexual challenges that went unaddressed when they were small.

This raises an interesting question for therapists. How do you help when a client’s sex issue is a reflection of an entrenched cultural belief system that we and our clients are all living with, or perhaps actually living out? When this is the case, your clients might not think they have a sex issue that can be helped. In a way, they’re right. Our whole culture has a sex issue.

On top of that, therapists have another level of challenge; how can we discuss sex without being inappropriate? While staying within our scope of practice? Without causing harm? Without making our clients overly uncomfortable? So, we developed an entire specialty called sex therapy. I should know; I’m an AASECT-certified sex therapist. And I can tell you, most of my clients don’t need a specialist. They need a therapist who is willing to have tough conversations, and who is willing and able to talk about all the difficult and complicated aspects of life we all struggle with from time to time.

Unfortunately, most therapists didn’t get sufficient training in working with sex issues. Many got none at all. This makes it very difficult to bring up and discuss complexities involving cultural messages, belief systems, sexual shame, pain, dysfunction, or subtleties of consent. That doesn’t mean you can’t handle these topics; it just means you might need to bolster your background knowledge, practice staying calm and grounded, and pick up some practical tools so that you know you can handle all the issues that are likely to come up.

So where do you start?

In my experience, simply by asking.

Here’s one thing I’ve learned from years of providing therapy about sex issues: your client probably won’t bring up their concerns about sexual intimacy if you don’t ask. The truth is, our clients are worrying about our comfort, and they are embarrassed. The cultural silence about sex means everyone thinks they are the only broken one, or the only one to whom sex is truly (freakishly?) important. They don’t want to put us on edge and they are afraid that if they discuss it, we will confirm their fear that they are broken or abnormal. And they are worried we will judge them. As therapists, we have to take the lead so that they know it’s safe to bring up the topic.

So, if you’re waiting for your clients to bring the issue to you without any prompting, you’ll keep waiting. And waiting. And waiting. Meanwhile, your client may be caught in a cycle of worsening physical, emotional, and relational problems that they’re too scared to seek help for.

By raising the topic of sex, you signal that it’s acceptable to talk with you about it. You go a little way towards reversing the decades of acculturation that have taught most of us that sex is something shameful, secret, and stigmatized. It also signals that you’re ok talking about tough topics, which is welcome news to every therapy client. And you’re normalizing sex. What a relief!

If I haven’t yet convinced you it is important to bring up sex in therapy, the first video in my free brief two-part workshop offers a deeper dive into the subject. If you’re already convinced, it’s still worth a look; the second part of the same workshop shares the easy and robust sex issues assessment I’ve taught to thousands of therapists all over the world.

Spoiler alert: I start by asking “Is there anything about sex or sexuality you think you might want to talk about in therapy?” If there is, I follow up with a handful of specific questions that help me figure out what is going on, so I can prioritize my treatment plan. This helps me target early interventions on the most relevant concern, both preventing potentially dangerous problems from getting worse, and helping the client experience some relief as soon as possible.

Of course, talking about sex in therapy doesn’t always go perfectly smoothly. That’s why I’m here to help. In my upcoming articles and webinar, I’ll share my approach for several tough situations:

• "Relational Work in Individual Therapy: Pitfalls and Possibilities," February 15th: Working with relational sex issues when you have an individual therapy client rather than a couple. What do you do when you can’t have both partners in the room, and therefore can’t see the whole dynamic, or help your client when the conversation gets tricky? This article will offer strategies to help.
• "The Intersection of Therapy and Medicine: Staying Within Scope of Practice," February 18th: Handling situations in which a sex issue is revealed that actually requires some specialized knowledge that you don’t have, like sex pain or erectile dysfunction.
• "Mindfulness, Pleasure, Happiness, and Desire," February 22nd: Discussing pleasure in an appropriate and helpful way.
• FREE WEBINAR, “Consent: Getting Beyond ‘Yes Means Yes,’” February 25th, 3 pm CST: Approaching the deceptively simple yet nuanced topic of consent. How we can help clients who are experiencing subtle (or not-so-subtle) pressure for sex? How can we model consent in the therapy room? Finally, how can we recognize consent issues while living in a culture that drastically misunderstands consent (and is often blind to consent violations)? You can save your spot for the webinar by signing up here.

Stay tuned...