Therapists often learn that sex is one of the most commonly neglected topics in session, both by clients and therapists. Clients are supposed to be able to talk about anything in therapy, yet many therapists still have a hard time signalling, let alone becoming aware, that sex is something we can (and in some cases should) be talking about with our clients.

Yes, there are therapists who undergo specialized training to offer services entirely devoted to talking about sex. And yes, if we don’t feel comfortable diving into the topic of sex with our clients, it is best to refer. But what about the space between when it comes up and when you determine a referral is appropriate? There is a lot of room there, in the subtleties of communication, for which we have a responsibility to manage any amount of sexual shame we hold so as to not project harm onto our clients.

What is sexual shame?

Shame makes us feel like we are inherently “bad.” Sexual shame causes us to feel like wanting sex and participating in sexual activities, in all its lovely and unique forms, is “bad.” It is the internalization of negative appraisals about sexual activities.

It must be noted that sex is diverse and variable for every person. This includes a number of factors to consider, including, but not limited to:

• Who it’s with (ourselves, one person, or multiple people)

• How much

• How desire shows up

• What objects/aides are included in sex (toys, lubricant, medication, contraception, etc.)

• Sexual fantasies

• What is pleasurable/not pleasurable

Any and all of these factors can have shame attached to them.

Why is it important to monitor?

You might think I get it. This is a no brainer. I know that sex is healthy and okay to engage in. Even with this top-down knowledge, many of us still operate with an unconscious bias that sex is something that needs to be hidden for various reasons. You might be unknowingly playing politics with yourself to construct a narrative of self in which you present an ‘acceptable’ sexual self (e.g., compulsory heterosexuality, vanilla sex, secret masturbation, hidden pornography use, etc.). This is a manifestation of sexual shame.

Even if your network of caregivers and community was sex positive, you still live in a world dominated by sex-negative ideology and messaging. As a result of this, you have likely internalized and adopted at least one negative opinion related to sex (and likely, more than one).

So, what happens when a client chooses to be vulnerable with you and initiate conversation about their sexual self? How do you ensure that residual sexual shame from societal messaging that many of us are insidiously exposed to doesn’t enter into the therapeutic space?

Given the power dynamic at play between therapist and client, our clients are positioned to be more susceptible to harm at our hand. We hold immense responsibility to ensure that our clients feel that they can talk about whatever they need to in a space that will be free from judgement. Since no human is totally free of judgement, we have to expend conscious effort to manage the impact of our judging brains.

There are two exceptions for which client safety may supersede other objectives (depending on the ethical responsibilities associated with your jurisdiction of practice): if a client has shared information to suggest they themselves or other parties are engaging in sex that is:

1. Unsafe

2. Non-consensual

Importantly, you can still assess for client safety while preventing the perpetuation of sexual shame (see how-to below).

Regarding the above, it is also imperative to reflect on what is considered unsafe and non-consensual. A therapist who is deeply entrenched in sex-negative messaging may impose value judgements onto practices that are, in fact, relatively safe and/or fully consensual. Here are two examples:

Example 1: There is significant stigma surrounding anal sex. To an unaware therapist, anal sex may be deemed unsafe. When in fact, this is an incorrect and reductionistic conclusion stemming from a homophobic legacy narrative that anal sex is unhygienic, taboo, and always involves a high risk of acquiring HIV. Among many other problematic parts, this conclusion disregards the safe sex practices that are utilized by folks who engage in anal sex (condom use, anal preparation, lubricant, HIV prevention medication, etc.). 

Example 2: An unaware therapist may also deem sexual domination as unsafe. Sexual domination occurs when one or more parties dominate someone or a group of people using words or physicality. When implemented safely, domination includes a consent discussion before engaging in the practices. These discussions make space for each party to express what they do and do not want from the interaction, including how to know if someone has become uncomfortable with what is happening or changed their minds during the interaction.

Ways that sexual shame can get projected into the room by a therapist

• Not initiating discussion around sex if it is relevant to the client’s presenting concerns.

• Avoiding talking about sex when a client brings it up. Note that clients won’t always bring it up explicitly, and in fact, they often don’t. It usually appears as a tentative, vague remark or unclear question. We can learn how to pick up on these moments by paying attention and by increasing awareness of our biases around sex.

• Commenting on a clients clothing (e.g., “It’s too cold outside for such little clothing”)

• Assuming pathology is present when a client brings up topics that are stigmatized in society (pornography, kinks, non-monogamy, group sex, role play, etc.)

I have encountered many folks in the BDSM/kink and/or consensual non-monogamy community who have quit therapy because their therapist attempted to uncover, in an unsolicited manner, reasons why they engage in those practices, as if there had to be something harmful that happened to them to drive them to these practices or identities. While life experience certainly impacts our choices, we must be mindful of the assumptions we place on specific groups. A monogamous person or someone who stays within the confines of ‘vanilla’ sex is just as likely as anyone else to present with relational and sexual “pathology” stemming from past adverse experiences, yet we do not assume as readily that there may be pathology present in these cases.

I witnessed a colleague receive supervision on a couples counselling case in which a woman was hurt and upset by her spouse watching porn. This was not the presenting concern for the couple, but simply an example of a larger non-sexual issue between them that spanned nearly all parts of their relationship. The therapist came from a faith practice that perceived pornography as a sin. It appeared as though she began to side with the woman after this information was shared. The therapist did not discuss or explore the use of pornography in the therapy room. In the supervision session, her question centered around how to get the husband to stop using pornography because she conceptualized that his use was one of the main causes of the larger non-sexual problems in the marriage. While there is a small chance that conceptualization could be true, there was not enough assessment completed around the use of porn and its impact on the couple to make that conclusion and subsequently influence treatment goals (which may have also been dictated by the therapists biased agenda). Although there is no way to know if this therapist’s actions in session and supervision were dictated by a biased agenda, it provides an example of how we may not be serving our clients as well as we could be if we do not reflect deeply on our biases—in this case, our biases related to sex.

How can I try to ensure I don’t perpetuate sexual shame towards my clients?

On your own time:

The first step might be to spend time, outside of sessions, reflecting on your biases around sex. Here are some reflection prompts:

• What does sex mean to me?

• What sex do I consider to be normal? Abnormal?

• What sex do I consider to be moral? Not moral? Do I believe that sex needs to be evaluated as moral/amoral? If so, why?

• To what extent do I get to decide what sex should look like for others? What authority do I have to determine someone else’s sexual practices? If I feel I have authority, what gives me that authority?

• What has influenced the above views?

• What credibility do those influencing parties/institutions hold?

To become more comfortable with conversations around sex, you may challenge yourself to speak more openly to friends or partners in your life about sex. While these conversations would occur in a different context, it may be good exposure if you feel uncomfortable addressing this topic with clients. You may also consider attending your own therapy with someone who specializes in sex or bring up sex related matters you are experiencing with your current therapist. The benefit of this latter suggestion is threefold:

• You would expose yourself to the discomfort of talking about sex,

• You may understand more comprehensively what it feels like for a client to initiate discussions around sex, and

• You may learn from the therapist, through modelling, what effective (or ineffective) responses and interventions look and sound like.
  

In the therapy room:

When there is evidence to suggest sex might be relevant to the presenting concern, here are some examples of how to introduce the topic.

• “Sex is an important part of many people’s lives. How important is it to you?” This allows space for those who identify as asexual, choose celibacy, and so on.

• “It seems like we haven’t talked about your sex life and I’m thinking that it might help me understand this issue you’re experiencing. Would it be okay for you if I asked you some questions related to sex?” You can never go wrong with explicitly asking for permission to talk about something.

• “What kind of sex do you like to engage in?”

• “What experiences in your life have influenced your sexual self-concept?”

Be mindful that erotic transference may impact if, how, and when you ask questions around sex. Just like any other form of transference, it’s wise to seek supervision. Discussing it in supervision is yet another way to practice exposing yourself to the discomfort that may arise when discussing sex.

If you are concerned about safety or consent or see that there is room to increase safety:

• “Did you make space before or during sex to communicate what you wanted during that encounter?”

• “What practices do you and your partner(s) engage in after sex to make sure you are each physically and emotionally okay?” In the BDSM/kink scene, this debriefing process is called ‘aftercare’.

• “If you are unaware of what resources are out there, I can share with you where the closest sexual health clinic is. Let me know if that’s something you are curious about.”

• “How were you able to tell if your partner(s) liked or didn’t like something that occurred during sex?”

• “Were you able to tell them what you did and didn’t like?”

I may intentionally opt for a closed-ended question (e.g., the final example listed) then follow up with an open-ended question. These questions can be hard to answer in an open-ended format for clients who have never been asked or thought about these things before. I find that it eases them into the discussion more smoothly and gives a preview of what’s to come following the initial question.

If you suspect that sexual shame may have entered the room through you or a rupture has occurred:

• “You know, there is a lot of stigma around sex in our society. I’m sorry if I have brought that stigma into our conversation in any way. Have you felt that at all?”

• “There are some things I don’t know about X practice. I hope that my responses around X don’t come across as stigmatizing. Would you feel comfortable to let me know if that happens?”

• “What did it feel like to you when I said that?”

• “I’ll make sure to educate myself more on this before our next session.”

As therapists, especially novice practitioners, it’s impossible to know about every topic and presenting concern. This profession is a career-long journey of reflexive learning. I encourage you to be gentle with where you are at while also holding yourself accountable to a learning process. I recommend taking time to reflect on your blind spots and biases related to sex, educate yourself on those blind spots in manageable and realistic ways over time, and step outside of your comfort zone to practice how to speak about sex in sessions. Not only will this benefit your clients greatly, you may even experience personal liberation from sexual shame at the same time.

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