Treating Patients Means Talking About Sex

Sexual difficulties are common and encompass not only the sexual dysfunctions outlined in DSM-5, but other challenges such as unconsummated marriage, a couple’s abandonment of sexual behavior, infertility, incompatible levels of desire, and one partner’s preference for pornography or masturbation over partnered sex. Yet these challenges and others may go unaddressed in therapy because of challenges that psychiatrists and mental health professionals grapple with themselves, said Stephen Levine, M.D., in a presentation titled “Psychotherapeutic Approaches to Sexual Problems” at APA’s 2021 online Annual Meeting in May.

“We have to realize that there is a hidden high frequency of sexual difficulties in the population. The specific prevalence varies by problem type and age group, but it often exceeds 25%,” said Levine, a clinical professor of psychiatry at Case Western Reserve University in Cleveland. “Every study we have ever done has demonstrated that the prevalence in the general population is less than in the psychiatric population.

“These [difficulties] are the end products of nonsexual and sexual developmental processes, they are present in many of your patients, and they often play a significant role in your patients’ presenting problems of anxiety, depression, substance abuse, and even psychosis,” Levine said. “The question is, are they revealed to you during your sessions?”

Levine encouraged psychiatrists to review the content of their therapy sessions.

“Do you omit asking patients about [their] sexual lives unless they bring it up on their own?” he asked. “And do you steer away from the topic when the patient brings it up, where you note it and not follow up?”

Levine addressed four key challenges psychiatrists and other mental health professionals face in approaching discussions of sexuality and sexual difficulties with their patients. First, some mental health professionals may be struggling with problems in their own sexual lives and relationships, so they wonder how they would be able to help other people.

“All I have to say is that many sexual lives are problematic one way or another, and doing this work will help you understand your personal, private concerns or your partner’s difficulties,” Levine said.

Second, mental health professionals may not feel like they have enough knowledge to help other people. However, all that’s required is a moderate understanding of the condition a patient has, Levine noted.

“You don’t have to have an encyclopedic knowledge of every sexual dysfunction or every identity issue in order to listen well, ask questions, and make a few suggestions,” he said. “I also suggest that whether you’re a resident or a very experienced professional, it doesn’t hurt to read a little bit. There’s plenty to read in this area.”

Some physicians fear being aroused by hearing about a patient’s sexual experiences. While this is possible, it passes quickly, Levine said.

“This transient voyeuristic human response is not the beginning of a sexual boundary violation. It is something that we contain in our privacy, and it is something that only lasts a few seconds, if it occurs at all, so please do not be worried about this,” he said.

Levine added that some mental health professionals may not want to be involved in discussing sexual activities that they consider to be immoral.

“Your time-honored role is to understand the struggles of the patient. Overcoming your distancing mechanism will stimulate your professional growth,” Levine said. He added that psychiatrists who cannot overcome their distancing mechanism can work with other patients instead.

There is no single therapy for all sexual problems, Levine said. Options include psychoanalysis, cognitive-behavioral therapy, psychodynamic psychotherapy, interpersonal psychotherapy, sensate focus therapy (“sex therapy”), mindfulness therapy, couples therapy, group psychoeducational therapy, and bibliotherapy. He said that these forms of therapy are tools and do help patients, but which ones a mental health professional uses in therapy is largely a reflection of that particular professional’s training.

“We’ve all been educated to think in certain ways, but when you confront the array of sexual suffering and disappointment, you’ll see that no particular ideology [confers] the expertise to understand and overcome all of these concerns. We need to be much more reasonable and broad in our approach to this,” said Levine. ■