The Do’s and Don’ts of Sex Therapy With Queer Clients

There are a lot of different ways to support your queer clients and their sexual wellness. 

Some practitioners don’t work with LGBTQIA+ clients because they haven’t done enough training to feel comfortable. This means that it can be hard for lesbian, gay, bisexual, trans, and queer folks to find therapists and couples counseling practitioners who are located in their area.

This is especially true for trans clients.

First, the Don’ts of Sex Therapy With Queer Clients 

If you read this and realize you’re already doing great work with your LGBTQIA+ clients, I still hope you view it as a warm invitation for growth—to feel confident to grow your skills so you can continue to provide high quality care to a population that’s often quite deeply underserved. 

Also, I hope that if you recognize yourself in any of the DON’Ts listed here that you also view it as a warm invitation for growth—to continue to learn, and build your skills, competency, and knowledge. 

Don’t #1: “Gay Couples Are Just Like Straight Couples!”

I really think this often comes from a good place, but in our world where a nuanced clinical understanding of our clients is part of what makes our work successful, this one completely misses the mark.

Of course, this take is miles better than a pathologizing or prejudiced perspective on sexual or gender diversity, but it misses a lot of the nuance of the queer experience.

There are unique dynamics that LGBTQIA+ people experience as individuals and in relationships, and a thoughtful clinician will be attuned to those dynamics too.

There are also unique challenges, stereotypical roles, and difficulties that tend to arise in relationships with non-heterosexual configurations that are totally different than those that are common in straight relationships.

I think it’s fair to compare this “just like straight people” sentiment to the cringe-worthy and offensive “I don’t see color.”

In both of these statements the speaker might be trying to convey: “I’m friendly, and I don’t want you to think I’m a bigot.”

But the listener hears: “Not only do you not really understand my experience in all its beauty and pain and complexity, but it also sounds like you’re trying to erase it completely.”

If you don’t have much experience working with LGBTQ+ clients but you’re open to working with them, it’s better to just say that instead. 

Don’t #2: “Are You the Top or the Bottom?”

We all know the saying about what happens when we assume, and I’d like to think clinicians have learned this lesson more explicitly than most. However, there’s an assumption trap for those who are inexperienced in working with queer and trans people: to try and apply what they know about heterosexual relationships or the cisgender binary to understand their LGBTQ+ clients. 

This can lead to some truly misguided questions, including conflating genitals with gender and wondering how a same-gender couple decides who will take on which traditional gender role in the relationship.

If we assume that queer sex looks just like the straight sex we are familiar with, not only are we likely to feel confused, we’ll struggle to understand the true dynamics at play. 

Some gay men don’t enjoy anal sex at all, many trans people never want surgery at all, some nonbinary people have an outward gender expression that matches their sex assigned at birth and some don’t—I think you get the point.

Don’t make assumptions about who your client is as an individual, how their relationship functions, what their political leanings might be, what their body parts look like, or what they like in bed based on their gender or sexual orientation.

Don’t #3: “I Know You’re Here to Talk About Anxiety, but I Saw Your Legal Name Is Jonathan… Are You Transgender? Have You Had Surgery Yet?” 

There’s a painfully common experience, nicknamed the “Broken Arm Syndrome,” in which trans people seek medical care for something—like a broken arm—and medical providers fixate on their gender instead of providing them the care they actually need.

The imaginary quote listed above as a DON’T may seem extreme to you.

Why would that clinician need to know about the client’s genitals before getting to know them, if at all? But sadly, this really happens to people!

Imagine some of the most private parts of your life—your erotic self, your own genitals, how they function and how you feel about them, and how you came to understand your own gender and sexuality—constantly being called into question when you seek routine medical care. Imagine if sometimes people started to ask you about your gender or genitals aggressively, or if they refused to treat you after you answered, saying that they don’t specialize in seeing people like you. 

Sometimes they might say that even if they specialize in exactly the thing you need help with, like  a spider phobia. It would be reasonable if you became uncertain about seeking care, avoidant of new providers, and anxious or even reactive when a provider starts asking questions you sense are leading in a different direction. 

Of course, as therapists, we’re trained to ask lots of questions and really get to know and understand our clients, and we are often excited and truly interested in understanding the people we find on our couches.

To find a balance between our necessarily inquisitive natures and the way that can go off the rails for LGBTQ+ folks, I think it is important to lean on Lucie Fielding’s (whose excellent book, Trans Sex, you should definitely read) concept of “ethical curiosity.” She guides us to remember that we’re not entitled to know anything about our clients, that it’s our responsibility to seek their permission to explore with them, and to remember to attend to the actual person who is seeking our care. 

While our brain might light up at something like their trans identity or their polyamorous relationship configuration, if they have a broken arm or a spider phobia they are seeking treatment for, the ethical thing to do is to recognize their concern as the issue to address.

Our curiosity about other parts of their life should be regarded as our own emotional intrigue, and not a clinically important matter to pursue without their permission.  

Next, the Do’s of Sex Therapy With Queer Clients

Just as there are questions and statements to avoid when working with LGBTQIA+ clients, there are  some things you can (and often should) do to let your clients know that they’re in a safe and supportive space in session with you. 

Do #1: “I’m Totally Comfortable Hearing About it If You Want to Share the Details With Me.”

It’s really important to make it clear that you’re a safe person for your clients to be their whole selves with. This isn’t just about putting up a rainbow sticker in your window or checking a box in your online profile—although that’s a good start.

This is about giving your clients hard evidence they can trust you all the way through their experience with you. This shows up in the language you use, the books you have or don’t have on your bookshelf, and the questions you ask and how you ask them. If you are open to working with queer clients, what proactive steps have you taken to let them know you will provide them with affirming care?

Do: #2: “You’re Planning a Trip to [City, State, Country]. Is That Some Place You Feel Safe Visiting?”

Be aware of intersecting identities and trauma from oppression and violence. While there have been serious changes normalizing queer and trans peoples’ existence and increasing their rights, there’s a long and continuing history of violence, discrimination, marginalization, and oppression that‘s likely to have continued impact on the LGBTQIA+ people in your life, including your clients. 

I am continually surprised at how quickly the cultural winds of change can switch directions, and when your rights, your family, and your physical safety are at risk, that can have a profound effect on your life.

There’s no way to adequately provide mental health care and support for LGBTQ+ clients without understanding and acknowledging that impact.

Do #3: “I’m Excited You’ve Been Talking With Your Doctor About Gender-Affirming Medical Care! If Anyone Requires a Letter From Me, Please Know I’m Happy to Provide It.”

Even though there are a variety of philosophies and opinions about the fact that trans people need to get a “sign off” from a clinician to make their medical decisions, the fact remains that it’s a part of the process for some surgeries, and it can be difficult to find therapists who are open to providing a letter.

 If you are open to it, consider getting training in writing letters for trans folks who need them to receive gender-affirming surgeries.

As always, there’s no substitute for getting additional training so that you feel comfortable providing affirming care, and being able to share that you’re comfortable with and capable of providing the care your client needs.  

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