Talking about S-E-X in Healthcare Settings

Abstract

Sexual health is a foundational aspect of health and wellbeing, yet many healthcare and mental health providers avoid conversations about sex with their patients. This article explores how inadequate training and systemic discomfort around sexuality lead to missed diagnoses, invalidation, and harm—especially for LGBTQIA+ individuals and other sexually marginalized communities. Drawing from clinical experience and current research, the author outlines how silence around sexual concerns can deepen shame, perpetuate inequities, and drive patients away from care. This article offers practical, affirming strategies for initiating these essential conversations and encourages clinicians to reflect on their own values, biases, and knowledge gaps. This work calls on all healthcare professionals to normalize discussions of sexuality as routine, respectful, and integral to care—not peripheral.

Introduction

As a sex educator with 25 years of experience and the founder of a group practice that centers sex therapy, relationship therapy, and psychotherapy for sexually marginalized communities, I’ve seen firsthand the harm that occurs when healthcare professionals are not adequately trained in the full spectrum of human sexuality. This includes the diverse sexual behaviors, expressions, identities, and orientations across the LGBTQIA+ spectrum and beyond. Too often, queer, trans, nonbinary, intersex, and asexual clients—along with those exploring kink, polyamory, or sex work—suffer in silence because we as providers haven’t opened the door to ask even the most basic of sexual health questions. When we fail to approach sexual health with curiosity, respect, and clinical competence, we risk misdiagnosing, mistreating, or simply overlooking what matters most to our clients.

These harms aren’t always driven by malice or willful ignorance. Many happen in the blind spots of our own limited training, especially when sexuality is treated as peripheral instead of integral to health and well-being. Here in Delaware, harm happens every day when providers ignore or inadequately address sexuality, or when they treat sexual concerns through the narrow lens of their own values rather than from a foundation of evidence-based, sex-positive, LGBTQIA+ affirming care.

So let’s crawl beneath the (fact)sheets together and ask the hard questions: Why is this happening? What can we do differently? And how do we continue to grow as clinicians and caregivers to better serve the diverse sexual health needs of all our clients?

To My Fellow Healthcare Providers

To my fellow healthcare providers, I have a true story to share with you. I know of a 19-year-old college student in Delaware who sought help from a local therapist. She was feeling depressed and insecure about her sexuality and experiencing some challenges in her sexual functioning, so she believed. She made the brave decision to seek therapy, picked out a therapist, and went to her first few appointments, sharing information about her life, her difficulties, and her worries. As she continued with therapy appointments, she noticed that her sexual concerns were being overlooked, ignored. When she eventually asked about when and how the sexual issues might start to be addressed, she was told that the sexual challenges weren't her “real” issue, and that she had “control issues,” and that’s the work that she needed to do. She felt deep shame about that response and stopped asking. She continued with that therapist for a while longer, believing the therapist must be right, after all. And the sexual challenges persisted. That college student eventually stopped therapy, actually feeling quite a bit worse than when she entered, no surprise, especially since her presenting problems had been categorically neglected and invalidated. Further, the clinician had done harm by not only disregarding the presenting problem, but also by creating more shame by ignoring it and judging it (“you just have control issues”), and also failing to refer out to a trained sex therapist when the clinician clearly had no training in treating sexual concerns. So, what happened to that patient? Well, 30 years later, she went on to write the words you’re reading in this article right now. Nice to meet you.

Why Aren’t Conversations Happening? Lack of Training in Healthcare and Mental Healthcare Institutions Is Systemic.

A trend in the lack of knowledge in our healthcare providers is systemic, originating in the universities and organizations that train doctors, nurses, and therapists. These institutions typically don’t value sexuality and sexual diversity. Academic programs that train doctors, nurses, therapists (psychologists, counselors, social workers and marriage and family therapists) and other healthcare providers do not offer typically comprehensive coursework that covers sexual diversity, sexual function, and treating sexual concerns and dysfunctions¹ or how to competently serve sexually marginalized populations like lesbian, gay, bisexual, transgender and queer (LGBTQ+) members. One study found that the average amount of education medical schools require in sexuality education is only 3-10 hours total over the course of four years.² That’s only a half to barely over a full day of education. And regarding the mental health field, while it would make sense for potential clients to assume competence around sexuality in their psychotherapists, surveys show that few psychology and counseling programs “offer comprehensive training in sexuality… sex therapy, sexual expression” and more.³

Why Aren’t Conversations Happening Between Provider and Patient? It’s Because You’re Not Asking. But, Your Patient is Waiting for You to Open the Door.

Here’s what we know about the lack of discussing sex and sexuality with your patients: at the very least, we as providers are missing so much vital information and at worst we are doing harm.⁴ A common mistake many providers make is assuming that your patient is going to bring up sexual concerns spontaneously without you asking. Nope. More often, your patient is hoping you’ll ask. They are waiting because they are wondering if you are a safe, open, nonjudgmental space for them to share their sexual concerns. They are looking to see if you’re going to ask them first, and if you will be comfortable talking about sex with them. Unfortunately, your silence is probably telling them all they need to know. A study from researchers at the University of Chicago found that while almost two-thirds of OB-GYNs regularly asked about their patients sexual activity, this only skimmed the superficial surface, and most did not ask follow up questions nor inquire about orientation nor identity. Just 40 percent of OB-GYNs noted that they assessed for sexual problems or dysfunctions, less than 29 percent regularly asked about sexual satisfaction, and only 28 percent confirmed their patients’ sexual orientation (LGBTQ).⁵

However, we know that in general, your clients want to be asked. One research survey revealed that 99% of patients who had presented for regular gynecologic care reported at least one sexual concern.⁶ Of those who reported concerns, these were the most common reported:

• Lack of interest in sex (87%),

• Challenges with orgasm (83%), and

• Painful sex (72%).

In another large international study of 27,000 mixed-gender study participants, the results showed that over 50% reported at least one sexual problem/concern.⁷ However, only 19% of those had sought out a health provider or care for that concern, and only 9% had a health provider who had asked them about their sexual health in the prior three years.¹

Please start to ask yourself these questions with compassion and curiosity: If you’re not bringing up questions about sex and sexuality with your patients, is it because you’re not comfortable doing so? Is it because you don’t know where to start? Keep reading, we will get there together.

How Do I Start Talking About Sex/ Sexuality with My Patients? (Prerequisites).

These recommendations can be pre-requisites, but I want you to think of these as co-requisites, meaning you can get started with asking your patients right away if they have any sexual concerns or if they have anything about their sexuality they would like to discuss with you. But when you do, make sure you are ready to respond nonjudgmentally, able to offer support and resources, especially to LGBTQ-welcoming and friendly services, and refer out if you are not comfortable and competent in treating any concerns they bring up.

Here are the other prerequisites and corequisites for competently addressing other areas of your patient’s sexuality, the most powerful (and fun) one first: work on your own sexuality. Yes, really. Read sex books and listen to sexuality education podcasts and watch sexuality education videos and attend sexuality workshops and conferences. You will probably have a WONDERFUL time. Learn about your own pleasure and connect more deeply with your body’s capacity for relaxation, pleasure, and sensuality. Get more practice talking with your partners about sex, deepening your understanding about your own sexuality, and as you do, you will get more comfortable talking with your patients about their unique sexualities. As you learn about your sexuality, you’ll deepen your understanding of how bodies work regarding sexual desire, arousal and orgasm, how our thoughts and values influence our sexual connections, how cultural shame can impact our ability to experience pleasure, and how your values influence how you approach your work with clients, all of these being critical insights how you address sexual issues with clients. Read that again. Last but not least, commit to lifelong learning by attending trainings and conferences and by joining professional sexuality associations like the American Association of Sexuality Educators, Counselors, and Therapists (AASECT.org), the Society for Sex Therapy and Research (sstarnet.org), International Society for the Study of Women’s Sexual Health (isswsh.org), the Association of Black Sexologists and Clinicians (theabsc.com) and World Professional Association for Transgender Health (wpath.org) to name just a few. See more here: https://www.aasect.org/related-organizations.

How Do I Start Talking About Sex / Sexuality with My Patients? (Doing the Work)

If you’re in any healthcare or mental healthcare setting, you can open the door to normalize talking about sex and sexuality by saying something like: “I believe it’s important to normalize talking about sexual health and sexuality as a critical part of each person’s life, so I ask routine questions about sex and sexuality of all my patients.” Tell your patients that most people have sexual questions or concerns about sexuality and this is a judgment-free zone. But, take this to heart: if you say this, you must mean it. Don’t promise this and then judge your clients for LGBTQ identities, or sharing with you that they are ethically non-monogamous, or into consensual kink, or participating in consensual sex-work. It is such a harmful experience when providers promise a “judgment-free zone,” and then patients are met with judgment and shamed by the doctor or therapist who promised safety. When I start asking questions about sexual health and sexuality, I always share with my patients that if there’s anything they don’t feel comfortable answering, just to let me know or say “I pass.” This makes your interactions very consent-based. I always give my clients the ‘right to pass’ on any question, just in case they’re very uncomfortable or tempted to minimize something or make something up to protect any sensitive information.

If You’re a Healthcare Provider, one model you can use to guide your sex questions is with a Sex History Risk Assessment using the 5 P’s recommended from the CDC website,⁸ but in truth, I recommend adding two more P’s to that sex history list. As a medical professional, you’ll want to open the door and ask about:

1. Partners (genders, orientation),

2. Practices (sexual behaviors),

3. Past history of STDs,

4. Protection from STDs and unplanned pregnancy, and

5. Pregnancy plans.⁸

But here’s where as a sex educator, a sex therapist and a sexologist, I’m begging you to go further, I need you to add two more Ps to your medical sex history risk assessment:

1. Pleasure and

2. unwanted Pain.

Ask if sex is pleasurable for them and if they have any concerns about their sexual functioning. Ask if they experience unwanted pain during sex. These last two questions are critical because typically patients will not bring concerns about sexual functioning (pleasure) up unless asked, and far too many people minimize and normalize pain associated with sex, and this is often missed in regular routine care unless directly asked point blank. Please, ask.

If You’re a Mental Healthcare Provider, start the conversation about sex, orientation, gender, partners, and expression from the first appointment. As a sex therapist, I have had so many patients who find me and our center because of our expertise with sexuality, sex therapy, and working with sexually-marginalized populations. So many of our clients describe leaving their previous therapists, who were otherwise a good fit, because they just hit a wall where they couldn’t move forward as the therapist either wasn’t comfortable discussing sexuality, or couldn’t treat any sexual concerns. Other patients come to me after experiencing years without mental health care after an experience of harm with a therapist. Common examples of harm include therapists who insisted that the patient’s interest in kink could only be a result of trauma (it’s not), therapists who judged and shamed clients for doing chosen and consensual sex work (sex work is real work), therapists who spent the client’s time (and money) having the client educate them on sexual orientation and gender identity instead of doing their own work on their own time, therapists who told clients that all porn use is addictive (absolutely false and not based in science), and therapists who insist that any relationship structure that isn’t monogamous is indicative of attachment problems or commitment issues (absolutely not). Whew.

If your clients are making consensual choices, stay curious. Don’t judge. Read everything you can. I’ll include a brief reading list at the end of this article to get you started. Commit yourself to being sex-positive, inclusive, intersectional, trauma-informed, and anti-racist. All of these have deep connections and intersections.

So where to start asking? Your patient’s sexuality is an inherent, critical part of who they are, just like every other piece of their life. Even if your patient’s sexuality wasn’t part of their list of presenting concerns, it’s important to cover sexuality and sexual health questions starting at the intake. It’s fundamental to know about sexual orientation, sexual attraction, gender orientation, pronouns, gender expression, partner or partners, and ask them to tell you if there’s anything important for you to know about their sexuality. Ask them if there’s anything about their sexuality that they think they might want to discuss in therapy. If the answer is no, let them know that the door is always open for sexuality to be discussed in therapy anytime. If it’s couples therapy, ask about the couples’ sexual life and what it is like for each of them. Ask them if they have anything they’d like to discuss about their sexual life, and if the concerns bringing them to seek couples’ therapy have also affected their sex life (likely, they have).

Treating Client’s Sexual Concerns & Referring Out.

Working with and supporting client’s sexual concerns is an amazing creative and delightful magical area of work. However, if you do not have the training and education to treat the client and their presenting sexual concern, please consult, get training and/or refer out to competent sexually-trained professionals. Expand your training, your education and your professional network in order to help your patients get the most sex positive and comprehensive and supportive care they can get. Believe your client. Believe your client’s experience of pain, and support your client in their goals. Do not, please, do not tell your clients to have a glass of wine or other alcoholic drink to relax before sex which 20% of medical providers do when, according to one study, women share they have pain with sex.⁶

What Are You Going to Do Tomorrow?

In closing, you’re still reading this article so I still at least somewhat have your attention. What are you going to do with this information? Let me close with a “Call to Action.” Please do one thing, maybe three.

1. Buy one of the sexuality books I recommend on the accompanying list.

2. Commit to starting to ask every patient about their sex life.

3. Commit to adding LGBTQ resources to your referral network.

4. Join AASECT.

5. Become a certified sex therapist.

6. Become a specialized sexual health provider.

Jump in with me! Let’s get clinical.

To the Patient: Time to Ask What’s Up Doc? Is Sex Missing from your Healthcare Conversation? Time to bring it up.

First and foremost, you are 100% normal. Sexual concerns and worries are normal and common, uncertainty about optimal sexual functioning is normal, you are normal. I often validate my clients by telling them, ‘no one grows up in this culture with their sexuality unscathed.’ It’s common to feel unsure, or have worries or insecurities. And while sexual shame as a result of a repressive culture is normative (common), it’s not helpful and you don’t deserve to feel that way. And you certainly don’t deserve to have your sexuality, your identity, your sexual interests, orientation, gender, behaviors, expressions in any way shamed, judged, or ignored by your medical providers. If any of these have happened, please advocate for yourself if you think it might help or find a provider who can serve you better. You deserve great care!

So how do you get started with having your sexual health and sexuality included in healthcare? First of all, if you have noticed that you are not getting asked about your sex life in routine healthcare, or your mental health care, it’s a great time for you to bring it up. You can ask your provider if knowing about your sexual health and sexuality important for them to know. Ask them and then wait for them to answer. Their answer may tell you a lot. Are they warm and open and inviting and curious with a resounding yes? Do they seem uncomfortable? If you bring up a sexual concern, notice if your provider listens, gets curious, supports you, believes you, and wants to get you answers, treatment and resources. Or, do you leave their office feeling not believed or invalidated? I want to share a case of a recent study of patients with sexual pain disorders who had attempted to access medical help had disheartening findings.

Research participants reported that they found about 34% of their providers to be supportive, 32% they noted were “belittling,” 31% did not believe the patient, over 41% had been told to “just relax more”, and over 20% of patients had been told by their medical providers to “drink alcohol” as a recommendation. What’s more, just under 40% of these patients noted that they were “made to feel crazy” and most (around 53%) considered ceasing care due to these experiences.⁹ It’s important to emphasize that this study was only able to capture patients who continued with treatment, and not the scores of patients who gave up on treatment after experiences just likes these. If you are feeling less than confident and supported by your provider, find another provider. Supportive, competent, compassionate sex-positive well-trained providers are here in Delaware.

Pleasure is your birthright and advocating for your sexual health, sexual rights, dignity and respect needs to be a given. Please check out my recommended reading list to get you started or continue your path of sexual wellness & joy.

Reading List

• Black Girls' Guide To Couples' Intimacy; Dr. Lexx Brown-James

• Come as You Are: The Surprising New Science that Will Transform Your Sex Life; Emily Nagoski, PhD

• Come Together: The Science (and Art!) of Creating Lasting Sexual Connections; Emily Nagoski, PhD

• Gender Magic: Live Shamelessly, Reclaim Your Joy, & Step Into Your Most Authentic Self; Rae McDaniel

• Good Sex: Stories, Science, and Strategies for Sexual Liberation; Candice Nicole Hargons, PhD

• Naked at Our Age: Talking Out Loud About Senior Sex; Joan Price

• With Sprinkles on Top: Everything Vanilla People and Their Kinky Partners Need to Know to Communicate, Explore, and Connect; Stefani Goerlich