Why All Therapists Can (and Should) Ask About Sex?

Q: Is it essential for therapists to ask clients about sexual issues? I don’t want to go outside of my scope of practice, find myself in a conversation I have no idea how to navigate, or make clients uncomfortable.

A: Your concerns are understandable; most therapists don’t have much, if any, training working with sex issues. And beyond the lack of training, most of us—clients and therapists alike—rarely experience truly comfortable conversations about sex in our daily lives. At the same time, challenges around sex and sexuality are part of the human experience, and they’re often accompanied by a fair amount of distress. Most of us have had to muddle through these issues on our own, contending with shame and misinformation along the way, but what if we didn’t have to go it alone?

Most clients are grateful for the opportunity to discuss sex, often reacting like you’re throwing them a lifeline when you communicate that sex is a welcome topic in the therapy room. Even if they don’t have something particular to discuss, they’re usually glad to know they’re in a safe space to talk about sex if they ever need to. I’m not speaking solely from my own experience: I’ve trained hundreds of generalist therapists to discuss sex, and I’ve heard, over and over again, that clients were much more receptive to the conversation than they assumed.

So, if there’s a small part of you that’s curious about discussing sex issues in the therapy room, let’s lean in. How could you bring it up? And what would you do if it went badly?

Opening the Door

“Is there anything about sex or sexuality you think you might want to discuss in the course of our work together?” I ask this as part of my assessment, right along with questions about anxiety and depression. In that context, I don’t think sex needs to be particularly intimidating. You’re already asking your clients forthright questions about very sensitive, emotionally charged material. I’ll bet that, when you started out, it was challenging to ask detailed questions about suicidality, but you learned how to do it, with some practice. You can reach a similar level of confidence when it comes to asking about sex, too.

Sometimes my client will respond, “no,” and I’ll say, “That’s just fine. If anything arises, just know you can bring it up here.” I’m not interested in pressuring them, and I’m not invested in what topic we talk about. I see my role here as offering a buffet of conversation topics that are often relevant to therapy.

On rare occasions, you might have a client who says something that indicates a lot of discomfort, some version of, “Oh no, that’s gross, why would we talk about that?” In that case, I’d say something like “Good question! I don’t actually think sex is gross, and lots of people have concerns or questions about it, or distress about it. If that’s you, I’m here for it. If not, that’s fine, of course.”

I’ve never had anyone say, “I think it’s malpractice to ask me about sex. I can’t believe you did it, and I’m leaving now.” If that were to happen, I’d say, “Thank you for your honesty. I’m so glad you spoke up. I didn’t intend to make you feel uncomfortable. I ask everyone about a lot of things, including sex, and we don’t have to discuss it, or any particular topic, unless you want to. One thing I can promise you about working with me is that I’ll honor it when you tell me you don’t want to talk about something, and I really want to know what’s important to you. Would you be willing to consider staying? Are there things you’d like to ask me that would help you figure out if this is a safe place for you?”

You might notice that there’s a common thread here: consent. I introduce the topic as a conversational option, and my client gets to decide if they’re interested in pursuing it. I always seek to model consent in my work, no matter what’s talked about. If a client says they don’t want to talk about something, I might ask why, or what’s coming up for them, but I’ll certainly honor their boundaries, and I’ll let them know that I think it’s important and wonderful that they’re being clear with me about what they want. I strive to be attuned, create safety, reward honesty, and identify options they may not have considered. In nearly every case, this approach results in a strengthening of the connection between me and my client.

The Cost of Not Asking

The reality is that not asking about sex—though it might feel like a neutral choice—comes with a cost. Many of my individual clients have shared something like, “Thank you so much for being willing to talk with me about sex as if it were a normal part of life. I was able to do a huge amount of healing in a really short period of time because you were so comfortable with the issue.” In addition, I can’t tell you how many partners I’ve seen over the years who’ve told me some variation of this story: “We’ve been to a number of couples’ therapists over the past 25 years, and you’re the first one who’s ever brought up sex. Now that you mention it, sex has always been difficult for us.”

Of course, those therapists probably didn’t bring up sex because they were justifiably concerned about respecting boundaries. I respect their caution, but at the same time, I’ve found that most clients who discuss sex with me don’t need a specialist at all. They need a therapist they trust who’s curious, interested, and willing to talk frankly about anything that’s important to them. They need someone who’s willing to walk beside them as they unpack their thoughts, feelings, confusion, early influences, and future aspirations. I believe that could easily be you, the therapist they’re already working with.

Much of the work you do in this area will involve dynamics you already have experience with. Your clients will wonder if their experiences are normal, if they’re broken, and if there’s hope for them. They may wonder if there’s a future for their relationship if their partner wants a different type or frequency of sex than they do. They may have a limited sexual repertoire, experience some sexual dysfunction, or have difficulty handling disappointment when sex doesn’t go as planned. Commit to a nonjudgemental stance and use the therapeutic tools you already have in your toolbelt.

When you’re unsure of something, it’s okay to be honest about the limits of your expertise. It’s much more important to be in the conversation than to know the answers, so please don’t let the likelihood that you won’t know something at some point stop you from talking about sex in therapy.

It would be very powerful to say, “There’s so much misinformation about sex that I don’t want to make a guess. I think you deserve real answers to your very important questions. Can you think of any steps you could take to get the information you want?” I might encourage my client to look into a topic that interests them and see what they can learn.

To Refer or Not to Refer

Some of your clients will make great progress on their sex issues through their work with you, particularly if you encourage them to learn more about it. If the progress seems slow or the treatment isn’t progressing as you anticipated, I strongly recommend consulting with a sex therapist. The investment will pay off many times over, not just with this case, but with future clients. I consult when the treatment plan isn’t moving along as I expect it to. If my consultant thinks there are specialists that could help me be more effective, I consider the pros and cons of collaborating versus referring. Many specialists will feel fine about doing just a handful of sessions with your client, with or without you present, without shifting the bulk of the work away from you.

Keep in mind that there are not nearly enough specialists to work with all the people who have sex issues come up at some point in their lives, because that’s pretty much everyone. Most sex therapists will want you to keep your client, because they don’t have room in their practice for more than a session or two. If you do need to refer to a specialist, the American Association of Sexuality Educators, Counselors, and Therapists (AASECT) certifies professionals in this area, and has a provider locator.

And hey, you might discover that you love working with sex issues! If so, it’s fairly easy to get extra training. You can expand your knowledge base a little and make a big difference for lots of clients. Or you could even expand it a lot and become a specialist.

Ultimately, sex has physical, emotional, relational, social, and spiritual implications. It’s a way many people connect with themselves and their partners, and gauge the health of their relationships, the health of their body, or even their moral wellness. It can be spiritually transcendent, completely casual, a quick release, a way to seek validation, a form of nonverbal communication, a source of shame, an energy exchange, an old wound not yet healed, or something everyone assumes you need to have, even if you have no interest in it at all. The meanings are infinite. This is truly rich material for therapy.

Sex also offers adults a rare opportunity to play—but often becomes so fraught that it feels more like work. Our relationship with sex isn’t static. It shifts over time, along with our bodies, lifestyles, relationships, and responsibilities. New sexual challenges emerge continuously, as do new possibilities. Every aspect of sex can be easy as well as incredibly difficult. Sex can be deeply satisfying or leave you feeling lonelier than before. There’s so much confusion, misinformation, judgment, and fear about sex that I truly believe you can create a significantly reparative experience for most clients simply by opening a conversation about it and easing the loneliness that comes with all taboo but important topics.

And if you’re still wondering if your clients will want to talk about it, all it takes is one question to get started. Give it a try. Let them surprise you.