Why I Ask About Sex (And Why You Should Too If You're A Mental Health Provider)
For many people, sex matters. A lot.
Which means, for many people, if your sex life is derailed, it matters. A lot.
We are sexual beings from birth till death. Look no further than the rising STI rates in the geriatric population and you can clearly see that sex matters to people across the lifespan. While the emphasis one places in their sexuality can change over the lifespan, sexual relationships continue to remain a stable predictor of relationship satisfaction, life satisfaction, and emotional well-being.
When we consider the multitude of systems involved in healthy sexual function--anatomical, physiological, neurological, hormonal, neurochemical, relational, psychological, (get the point?)--not to mention the critical role of culture and religion, the likelihood that someone will experience something that can can negatively impact their sexual health is pretty high.
So, let's recap what we know so far:
1. Sex matters to many people across the lifespan
2. There are many possible factors that could derail healthy sexual function.
So, why is it specifically important for mental health providers to ask their clients about sex?
Sexual dysfunction is not a specific diagnostic criteria for any mental illness (aside from the category of sexual disorders of course), but virtually every mental illness has symptoms that can manifest as a sexual dysfunction. Anhedonia, or loss of interest in pleasurable activities, is a core feature of depression. Heightened muscle tension, feeling jittery, or excessive worry are all common features of anxiety. Strong physiological reactivity and emotional detachment are common features of post-traumatic stress disorder. Intense discomfort with one’s physical body can be present in body dysmorphic disorder or gender dysphoria.
The list goes on and on. Any of these diagnostic symptoms can manifest in alterations to sexual function. But unfortunately, sexual health may fly under the radar since it is often not specifically assessed as a byproduct of these conditions.
Additionally, anything, and I mean ANYTHING, can impact sexual function on an acute basis. Stubbing your toe, having a stressful day at work, chasing kids around the house, or not sleeping well the night before, can all result in one’s body not functioning as desired during sex. The many psychosocial stressors our clients deal with, which may often be the focus of psychotherapy, can also directly influence one's sexual experience.
But, despite the ubiquity of sexual health concerns, many mental health providers don’t ask about sexual health. Why might that be? Well, for one, many mental health training programs offer little, if any, structured education about assessing or treating sexual dysfunction. Few field placements or internship sites offer specialty care in sexual health and therefore place little emphasis on educating trainees, resulting in clinicians feeling a lack of competence in this area. Clinicians may worry about crossing personal boundaries by asking a client about their sexual function or may fear being seen as “odd” or “perverted” by their clients. Clinicians may themselves feel uncomfortable openly and directly discussing sexuality or sexual function with their clients.
So, on the one hand I’ve seen an overabundance of mental health professionals who don’t ask their clients about their sexual functioning, and will actively avoid the topic, or attempt to outsource to a medical professional, when a client organically brings up concerns about sexual health. On the other hand we have a fairly strong likelihood that a client may experience some difficulty in their sexual relationship due to a disruption in one of the many systems involved in healthy sexual function.
What does this all add up to? Clients are implicitly, or at times even explicitly, told that psychotherapy is the wrong place to discuss their sexual concerns. Shame, stigma, and isolation increase the level of distress or discomfort a client experiences. A client may feel alone, unsure of where to turn, or frustrated by a lack of clarity on what might be going wrong. And, even when a client does seek medical attention, they are often told “that’s nothing to be concerned about” or “here, take this pill and everything will be fine” (I can’t count the number of times a client has told me they felt emotionally disregarded by their medical provider when reporting a sexual concern).
So, what does asking a client about their sexual health accomplish? It informs a client that, yes, this is an appropriate place to talk about sexual function. Even if your client does not have a concern they’d like to address, your inquiry about their sexual health opens the door to having this conversation down the road. Even if you are not trained in assessing or treating sexual dysfunction, you can validate your client’s distress, offer emotional support, and help guide them to the right person to help navigate a sexual concern. This ability to normalize and validate your client’s distress can do wonders in allowing your client to openly discuss their concerns. So, in our continued journey to see and treat our clients holistically, ask about sex. Your clients will appreciate it