Why it can feel so hard to say out loud
Many people who are comfortable talking about grief, conflict or anxiety in therapy freeze when the subject turns to sex. The International Society for Sexual Medicine (ISSM), describing sex therapy, notes that it is normal to feel anxious, especially at first, and that many people have trouble talking about sex at all, so discussing it with someone they have just met can feel awkward.
The reasons vary. Some people grew up in homes where sex was never mentioned, or mentioned only as a warning. Some worry they will be judged, or that what they describe is strange. Some do not have words for it beyond the clinical or the crude, and neither feels right in a calm office. Others are protecting a partner and feel disloyal describing what happens between them. All of these are understandable, and none of them means you are not ready for help.
What a therapist may ask, and why
Knowing what is likely to come up can take some of the dread out of it. Cleveland Clinic, describing sex therapy, lists questions about your health and sexual background, your sex education, your beliefs about sex, and your specific concerns. A psychologist may also ask about your relationship, your history, stress, mood, sleep and any medical conditions or medications, because all of these can play a part.
The purpose of these questions is to understand the problem, not to collect intimate detail for its own sake. Often the most useful information is not what happens in bed but what surrounds it: what you feel beforehand, what you tell yourself afterward, and what the two of you do or avoid saying to each other.
Ways to start when the words will not come
There is no correct opening line. Some approaches that people find easier:
- Name the discomfort first: "This is embarrassing for me to talk about." Saying it often makes the next sentence easier.
- Write two or three sentences at home and read them aloud, or hand the page over.
- Start with the relationship or the feeling ("I feel distant from my partner" or "I dread bedtime") and let the sexual part come later.
- Ask the therapist to ask you questions, so you only have to answer rather than find the words yourself.
- Use whatever words you have. Everyday language is fine, and you can ask what a clinical term means if one comes up.
- Say what you are afraid the therapist will think. Concerns about judgment are worth talking about in their own right.
You can set the pace
The American Psychological Association (APA) notes that if a problem is too painful to talk about, a psychologist should not push you to say more than you are comfortable sharing until you know each other better, and that it is fine to say you are not ready to talk about something yet. The APA also notes that a psychologist will let you set the pace when it comes to telling your story, and that as trust grows people often share things they did not feel comfortable answering at first.
In practice, that means you can talk about a sexual concern in general terms for a while, mention that there is more you are not ready to say, or come back to something a few sessions later. It also means you can tell the therapist when a question feels too much. A good therapist will take that as useful information rather than a problem.
If talking about sex has gone badly before
Some people have tried before: a doctor who brushed a question aside, a partner who reacted with hurt or anger, or a friend who made a joke of it. An experience like that can make the next attempt feel even riskier. It is worth telling your therapist about it, briefly, because it explains the hesitation and helps the therapist understand what you need. You might say, "The last time I brought this up, it did not go well." That sentence alone can make the rest of the conversation easier, because the person listening knows to take extra care.
What therapy for sexual concerns does not involve
Some people hold back because they are not sure what talking about sex in therapy might lead to. Both the ISSM and Cleveland Clinic are clear that sex therapy sessions do not involve any physical contact or sexual activity between client and therapist. Cleveland Clinic adds that if you feel uncomfortable with any aspect of therapy, you should tell your therapist, or stop seeing them and file a complaint. Therapy is a conversation. Any exercises suggested for home are your choice, and you can always say no.
If a partner is in the room
Talking about sex with a partner present brings its own difficulty: you may be choosing words with one eye on how they will land. It can help to agree beforehand on what each of you wants to raise, and to remember that the therapist's job includes slowing things down when a conversation turns hurtful. How to Talk With Your Partner About Sex covers conversations at home. Sexual concerns can be part of individual or couples therapy, and Dr. Lehmann can talk with you about which format fits your situation when you call.
When part of the problem is physical
If you have pain, changes in erection or ejaculation, vaginal dryness, changes since starting a medication, or symptoms around menopause or after having a baby, start with your physician, gynecologist or urologist. Do not stop or change a medication on your own. It still helps to tell your therapist what the doctor found, because worry about a physical change is often part of what makes it hard to talk about.
Dr. Lehmann is a licensed clinical psychologist whose approach is insight-oriented and integrative. She offers therapy for intimacy and sexual concerns that looks at the feelings, history and relationship patterns around a sexual difficulty. If you are curious about what sessions are like, see What to Expect in Therapy for Intimacy and Sexual Concerns.