Therapists and counselors of all types at least occasionally encounter clients seeking help with “sexual issues.” Typically, these individuals are worried about not enough sex, too much sex, bad sex, strange sex, or addictive sex. Sometimes these concerns are the client’s primary presenting issue, though just as often an individual’s sexual concerns are found lurking in the background, uncovered while exploring more overt problems like depression, anxiety, failed relationships, substance abuse, unresolved trauma, and the like.
Because sexual concerns are so often hidden, it is useful to add a few basic sex-related questions your initial assessment of the client. Non-threatening sexual queries include:
- Do you have any concerns about your current or past sexual behaviors?
- Has anyone close to you ever expressed concern about your sexual behaviors?
- Is there anything about your sexual life that feels shameful to you or that you try to keep secret?
Asking these and similar questions, and nonjudgmentally following up on pertinent responses, gives clients “permission” to talk about sex, letting them know it’s both acceptable and safe to discuss their sexual issues in therapy.
When sexual issues surface, therapists should consider the following:
- Is this a primary therapeutic issue that needs to be directly addressed?
- Does this issue need to be addressed immediately? (Is client safety or partner safety at risk?)
- Is this issue a secondary concern that should be pushed to the back burner until other, more pressing issues are under control?
- How, if at all, does this issue relate to and/or affect the overall treatment plan?
- Is the client’s concern pathological or just troubling to the client (usually for moral or cultural reasons)?
Therapists must also ask themselves if they are comfortable dealing with this issue, and if they have the needed skill set to do so. If the answer to either of those questions is no, a specialist referral is in order.
Common sexual issues that arise in therapy are as follows:
- Infidelity: Infidelity is not inherently pathological, though it can become so if it spirals out of control, as occurs with sexual addiction (discussed below), or if it causes problems with the client’s life functioning and/or mood. For information about treating both cheaters and betrayed partners, check out my books, Out of the Doghouse and Out of the Doghouse for Christian Men.
- Sexual Dysfunction: Various forms of sexual dysfunction are addressed in the DSM-5. Issues covered include delayed ejaculation, erectile disorder, female orgasmic disorder, female sexual interest/arousal disorder, genito-pelvic pain/penetration disorder, male hypoactive sexual desire disorder, premature ejaculation, and substance/medication-induced sexual dysfunction. Unfortunately, the DSM does not address porn-induced erectile dysfunction (PIED), a new form of sexual dysfunction that affects heavy and/or addicted porn users. Generally, clients who present with sexual dysfunction should be referred to an appropriate medical professional before the issue is treated with psychotherapy, as the issue is often physical rather than psychological.
- Sexual Addiction: Sexual addiction is a dysfunctional preoccupation with sexual urges, fantasies, and behaviors. Certified sex addiction therapists use three basic criteria to identify sexual addiction:
- Preoccupation to the point of obsession with sexual activity
- Loss of control over sexual behavior (usually evidenced by multiple failed attempts to quit or cut back)
- Negative consequences related to out of control sexual activity.
If you are uncertain about whether a client may be sexually addicted, this screening instrument may provide clarity.
Unfortunately, the DSM-5 does not directly address sexual addiction, which makes it more difficult to identify, treat, and seek insurance reimbursement for clients. Nevertheless, sexual addiction clearly does exist. The disorder was recently added to the ICD-11, listed as Compulsive Sexual Behaviour Disorder, and it will likely be added to the DSM within a few years. When it does look like a client is sexually addicted, that individual is best referred to a Certified Sexual Addiction Therapist. CSATs can be located using this link.
- Sexual Offending: The DSM-5 addresses sexual offending indirectly in material covering paraphilias, most notably in the sections discussing exhibitionism, voyeurism, frotteurism, pedophilia and sexual sadism. Of note: the legal definition of sexual offending varies from jurisdiction to jurisdiction, but the clinical definition—nonconsensual sexual activity—is a constant. Clients engaging in sexual offending behaviors are best referred to a sex offender specialist.
- Sexual Orientation: There are a few therapists (and clergy) who say they can “cure” homosexuality. They can’t. And their attempts at “reparative therapy” can be harmful to a client. Both the American Psychiatric Association and the American Psychological Association have issued strongly worded statements condemning the practice. The truth about sexual orientation is that you can’t change it, no matter how ego-dystonic it might be for a particular client (or the people around that the client). A therapist’s job when working with a client who is uncomfortable with his or her sexual orientation is not to change that orientation, it’s to help the client accept his or her sexual desires as a healthy and potentially enjoyable.
- Gender Dysphoria: Gender dysphoria is evidenced by a significant, longstanding level of discontent with one’s birth sex and/or the gender roles associated with that sex. Gender dysphoria is covered in detail in the DSM-5. As is the case with sexual orientation, psychological gender is fixed and immutable. Dealing with gender dysphoria, especially with clients who want gender reassignment surgery, is a highly specialized endeavor. If you are not trained for it, you should refer such clients to a specialist.
- Sexual Fetishes (Paraphilias): The DSM-5 addresses a variety of fetish-related arousal patterns, officially labeling them “Paraphilic Disorders.” These include voyeurism, exhibitionism, frotteurism (rubbing against someone without their permission), sexual masochism, sexual sadism, bestiality, pedophilia, sexual fetishism, transvestic disorders, and more. In all cases, to qualify as a disorder these conditions must persist for at least six months, and, more importantly, they must cause significant distress or impairment in social, occupational, or other important areas of functioning. Notably, it is not a therapist’s job to pathologize non-harmful, non-offending fetishes that are not causing distress.
If you choose to seek consultation with or to refer to another clinician regarding a client’s sexual concerns, you will most likely be consulting a therapist who is certified and/or trained in one of the following three areas:
- Human Sexology
- Sexual Addiction
- Sexual Orientation/Gender Identity
In addition to SexandRelationshipHealing.com, useful information and referrals can be found through the following organizations:
- AASECT: The American Association of Sexuality Educators, Counselors, and Therapists. This organization provides referrals for counselors who can help with non-addiction, non-offending sexual issues, along with training and certification.
- ATSA: The Association for the Treatment of Sexual Abusers. ATSA promotes evidence-based strategies for the assessment and treatment of individuals who have sexually abused/offended or are at risk to do so. ATSA provides referrals to qualified therapists.
- IITAP: The International Institute for Trauma and Addiction Professionals. IITAP trains and certifies sex addiction therapists (CSATs). They also provide referrals to qualified therapists.
- LA Gender Center: This facility offers counseling to sexual minorities, especially transgendered people. The center also offers trainings and continuing education.
- PFLAG: Parents and Friends of Lesbians and Gays. PFLAG provides education and support to families and friends of LGBT people.
- com: This site is filled with information about sexual issues, including sexual addiction, sexual offending, and the ways in which technology and sexuality intersect.
- Safer Society Foundation: The Safer Society Foundation is a dedicated to ending sexual abuse and offending through effective prevention and treatment.
- San Francisco Gay and Lesbian Community Center: This facility offers a wide variety of useful information and social support for gays and lesbians in San Francisco and elsewhere.
- SASH: The Society for the Advancement of Sexual Health. SASH is dedicated to sexual health and overcoming problem sexual behaviors, primarily sexual addiction. SASH offers both training and referrals.
- SAA: Sex Addicts Anonymous. This is a 12-step support group for sex addicts.
- SLAA: Sex and Love Addicts Anonymous. This is a 12-step support group for sex and love addicts.
- SA: Sexaholics Anonymous. This is a 12-step support group for sex addicts.
- SCA: Sexual Compulsives Anonymous. This is a 12-step support group for sex addicts. SCA is generally regarded as the most gay-friendly sexual recovery support group.
- SSSS: The Society for the Scientific Study of Sexuality. SSSS is dedicated to the study of human sexuality. This is a great organization to contact if you’ve got a client who is ego-dystonic about non-pathological sex-related issues (such as sexual orientation or a non-harming fetish).
- WPATH: World Professional Association for Transgender Health. WPATH is a professional organization dedicated to transgender health.