“Why do you ask?”
“How is my sex life relevant?”
“What are you going to do with this information?”
Clients sometimes ask very good questions when a therapist is focusing on things that do not seem related to the client’s goals. Sometimes they are also asking because the topic the therapist is exploring makes them uncomfortable. A trustworthy therapist should be able to, with minimal defensiveness, answer such questions and discuss the client’s underlying concerns, especially regarding sexual matters.
Human beings are complex, and a careful, skilled clinician will seek a broad understanding of the client prior to recommending change. This assessment process, when thorough, will include gathering information about the presenting problem, family of origin, current living conditions, physical health, mental health, developmental history, significant traumatic events, culture, ethnicity, spirituality, support networks, and sexuality.
In other words, therapy is an intimate process that invites the client to share details with a clinician that they have often not shared even with lifelong friends, lovers, or spouses. This level of disclosure should be supported by a trustworthy therapist who provides the warmth and structure that helps clients experience their risk-taking as ultimately positive and worth the natural discomforts of vulnerability.
Sex—especially one’s own sex life—can be a particularly difficult subject to discuss. Information about our sexuality is often closely guarded, for some because the topic feels taboo, and for others because they have experienced the distinct harm of having their own intimacies weaponized (i.e., physically, emotionally) against them.
If a client seeks out the services of a sex-therapy specialist, there is usually an understanding that the therapeutic process will involve talking about one’s sexual history, current sexual behaviors, inclinations, and preferences. But similar topics may feel unnecessary or even invasive when raised, for instance, by a therapist with a specialization in mood disorders with a client seeking treatment for depression.
What a client might feel to be intrusive may in fact be the therapist showing concern and respect for the depth and uniqueness of the client’s experience.
For instance, I have had clients suffering from depression ask me something like: “What do my mother and father have to do with this? They’ve been dead for years. I started feeling this way when I started my new job.”
After reassuring them of the relevance of this line of inquiry, I usually discover patterns of response to challenging life events that may have been established much earlier in life. In fact, these patterns are often evident in a parent who had a history of depression and passed on behavioral, emotional, and thought patterns, as well as genetic vulnerabilities, that created a likelihood of depression long before this client’s change in employment. Furthermore, a discussion of this client’s sexuality might reveal it to be a current contributing factor to their depression. Or it might reveal that the intimacies and pleasures of sex are a source of enjoyment that can be utilized as a defense against the severity and frequency of depressive episodes.
Often this type of assessment process allows both the therapist and the client to connect dots that might be initially viewed as unrelated.
A good psychotherapist will value and utilize their curiosity and interest in the client’s experience, pursuing lines of questioning that may be relevant to either their experiences of distress or their emotional resources. A good therapist will invite the client to pursue these avenues, even if the topic is initially uncomfortable for either the client or themselves, by exploring together the possible relevance of the topic and continuing to build the client’s trust in them.
A good psychotherapist will also guard against fishing expeditions: the pursuit of topics that have no logical connection to the client’s concerns but may be of interest to the clinician. This is particularly relevant when it comes to sexuality.
Let’s look at two accounts of how things can go awry in therapy around sexuality:
1. A woman who has seen four therapists over several years described to me her objections to questions all but one of her therapists have asked. Heterosexual male and female therapists have asked for details about her sexual acts with women that seem irrelevant to her therapeutic work. She had the impression that these questions arose out of the therapist’s personal curiosity about lesbian sex.
Her imagined worst-case-scenario was that one or more of them were sexually stimulated by her account. In separate instances, she was also left with the impression that the clinician was exploring the relationship of traumatic childhood events and her sexual orientation, suggesting to her that her sexuality was foundationally problematic. These implications were never directly addressed and undermined her confidence in therapy.
2. A heterosexual, male clinician described to me a session in which a homosexual male shared an early erotic memory. At the end of the account, the therapist responded enthusiastically, praising the eloquence of the description, even recommending that the client try to write about the event as an artistic expression.
Shortly after this session, the client, without explanation, ended treatment. The clinician realized afterward that his enthusiasm for the artistry of the narrative was a naked avoidance of his own discomfort (arousal?) and effectively communicated to the client that he was not ready to hear the client’s story and stay focused on the client’s therapeutic work.
While these personal experiences are subjective descriptions by individuals, they do provide cautionary tales about therapeutic discussions of sexuality. Some principles we may draw from these accounts include:
- Therapists need to explain the relevance of discussions about sexuality because a question that is not mutually understood as relevant feels suspect and threatens to undermine the client’s trust in the therapy.
- When a client and a therapist identify differently (i.e., sexual orientation, race, gender, culture), those differences can be understood as neutral facts, but they are facts that should not be ignored. For the therapist, self-awareness and careful supervision can help to prevent our very human responses from becoming unsound clinical decisions.
- It should be concerning to both the client and the therapist when a therapist’s assessment is detailed and thorough regarding sexuality and less detailed and thorough as to other aspects of the person.
- It should also be concerning if consideration of sexuality is excluded from the work by the therapist.
- Clients are not primarily responsible for the therapeutic relationship; therapists are. Clients have the right to expect and to hold therapists accountable for staying focused on the work at hand and providing the client with the information they need to do the work.
- Clients may benefit from letting a therapist know that they feel unsafe, disrespected, or that they have been given cause to question the intentions of the therapist.
- Most importantly, clients should be empowered to maintain boundaries in therapy that make sense to them by questioning a therapist’s intentions and—when they feel it is safe to do so—to disclose their fears and concerns about the therapist's motivations within the clinical relationship.
While discussions of sexual experiences or preferences may be very relevant in many therapeutic processes, it is also clear that sex need not be central to many other therapies. Given that people tend to be protective about their intimacies, therapists and clients will want to challenge the relevance of any particular question or issue.
Discussions about sex, much like discussions of other sensitive topics, like racism, present a challenge to both the clinician and the client to reach past their initial discomfort and explore together the distinctive intricacies of both the client’s problem as well as the breadth and depth of their resources for healing and change.