How Therapists Can Get Comfortable Talking About Sex in Therapy

Clients are often highly attuned to their therapist’s approval—or disapproval—of their own actions, beliefs, and personhood.

And, at the same time, they often turn to use for insights about their behaviors.

This is one of the many important reasons that as clinicians, we have to work through all our own stuff in order to be the good clinicians we aspire to be. We don’t want to impart harm in our sessions by telegraphing anything negative to our clients. 

If we have our own hang-ups or issues that we haven’t examined, it can be difficult to show up for our clients in empathetic, client-focused, and clinically appropriate ways. Talking about sex in therapy is no exception. 

The challenges of talking about sex in therapy

I recently heard two anecdotes from separate sex therapists that make this point beautifully. I was in a course with the prolific researcher and sex therapist Dr. Justin Lehmiller.

He was showing a word cloud illustrating the many sexual fantasies that people have and their prevalence. It was one of those word clouds where the larger a word is, the more frequently that response has been recorded. Dr. Lehmiller shared, laughing, that he needed to alter the visuals because if he didn’t, the cloud would just be the world “THREESOME” in big bold letters, dwarfing all the other responses to invisibility—because it’s such a popular sexual fantasy. 

A few days later, I heard about someone’s experience where they discussed their interest in a threesome with their therapist. The counselor told them: “That’s a paraphilia. That’s disordered, and that’s not a healthy or acceptable interest.”

Confused, this client then sought out sex therapy for help. 

If this person was pathologized by their therapist for sharing what some would see as a comically common fantasy with a clinician they trusted, what else are we getting wrong? And how can we do better?

Why talking about sex in therapy matters

People want to talk about their sex lives and sexual concerns (and sexual triumphs!) with their therapists and doctors. It can be scary to bring up, and some research on this shows that clients are often waiting and hoping that the clinician will do it first. Sex therapists in particular also often hear about the ways that things go awry. 

Some clients share bringing up a sexual concern in therapy—and then being referred out to a specialist in sex therapy with no further explanation, sometimes ending a meaningful therapeutic relationship abruptly. They also share the more subtle experiences of feeling shamed or rejected when talking about sex in therapy. They share experiences such as bringing up a sexual issue and having the clinician respond minimally and move on, indicating a lack of comfort with the topic to the client, or noticing the clinician’s difficultly discussing the topic without apparent embarrassment. 

We chose to work in mental health with the intent to help our clients and the clear desire not to cause harm, and we’re bound by ethical codes that require the same. Yet, when we’re feeling out of our depth and driven by our own emotional responses, that’s when we’re most likely to unintentionally impart harm. 

I invite you to imagine the experience of disclosing a sexual concern you might have to a trusted healthcare provider in your life. Think about your own body right now, how you feel about your genitals, and your own intimate moments with your partner or partners. Imagine mustering up the courage, feeling anxious or awkward. Maybe you use humor, or try to medicalize the issue to make it less intimate. The whole time, you’re trying to find the right words and the trust required of you to spit them out. Imagine maybe doing it at the last moment of the session, because you promised yourself you would do it this time. 

What might it be like for you if your provider responded with rejection, embarrassment, or avoidance? It seems highly unlikely you would feel helped by such an encounter, and quite plausible that it might increase your shame, or your resistance to seeking such support in the future. It might confirm for you that the thing you believe to be wrong about yourself—about who you are as a sexual being—is, indeed, very wrong.

I don’t mean for this vignette to shame the therapist by any means—we don’t get enough training and education about sex, as therapists or as humans, and this is hard. Instead, this imagined story is an invitation to embrace a topic that many of us have been told is dangerous, shameful, or awkward to delve into, and flip the script on it. Now, I invite you to take the suggestions below as concrete opportunities to make therapy with you a place where the unspeakable is safe to talk about—even when the thing you need to talk about is sex. 

How to get comfortable talking about sex in therapy 

1. Open the door 
Because sex is taboo and our clients often aren’t sure where we stand, it’s important to give permission for them to talk about it. Sometimes that’s explicit, saying something like “It’s okay if you want to talk about that.”

Sometimes it means asking a question or bringing the topic up first. And it always means attending to your responses (including the non-verbal ones) to make sure you’re expressing openness and comfort with the topic. As with any difficult topic, it’s important to signal to our clients that we welcome their openness and vulnerability. 

2. Get a framework 

If you can, read a book like Come As You Are by Emily Nagoski, or Mating In Captivity by Esther Perel. (These are just some of the other really good ones out there.) Having a professional framework for understanding and talking about the sexual issues your clients are experiencing can exponentially increase your effectiveness and confidence. These books written for a general audience are easy to read and integrate, and in my opinion they’re just so, so good.

3. Desensitize your giggles, blushes, or cringes 

This is one of my favorite tips because it’s so effective and empowering. There are probably some words or concepts that embarrass you or ick you out, whether it’s someone who calls their partner “Daddy,” the word anus, or the idea of threesomes. The good news is those emotional responses extinguish just like any other. In training to do sex therapy, we have a course designed to assess our sexual attitudes, and we watch and discuss sexually explicit content (aka pornography) with our colleagues for a long weekend. 

The idea is basically the same—to assess our own attitudes, biases, and responses in a safe setting where we aren’t going to impart those unexamined reactions to our clients. You don’t have to take it that far (unless you want to), but you can use the same approach. Repeat words that make you giggle in the mirror until they’re blasé. Learn more about a kink that makes you uncomfortable. Get a little more comfortable with your own erotic imagination.

4. Know when to refer out

Remember your ethical decision making skills. Know when you’re getting out of your depth and have a network of experts who you can refer to, in case an issue comes up with a client that’s beyond your clinical competence. If you know what you can’t do, it also means that you know more clearly where you can focus on improving your competence and skills. Having a road map reduces a lot of the anxiety around stepping onto roads you don’t know well. Knowing when to refer and to whom also reduces fear around those issues that you aren’t confident with coming up in session. It also means getting comfortable having a compassionate, open conversation with your clients about those referrals when you have to make them. 

5. Know your blind spots

This is about your personal stuff. Did you grow up believing that homosexuality is a sin? Were you shamed by a relative for masturbating when you were young? Did your ex-partner watch a lot of porn and it was something you fought about when you were breaking up? Do you secretly want to have a threesome, and you feel really icky about it and tell yourself it’s wrong? We all have stuff to work through, and we all know that our stuff can get in the way of our clinical work if we are unaware of it. Our feelings about sex is no different.  

And lastly, remember good therapy is good therapy. All the things that you already do so well in your sessions and with your clients still apply! Remember what you’re good at, and use those skills when you sex is the topic in the room.  

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