Bringing up sexuality can be nerve wracking. Some people are not used to talking about sex at all. Anxiety bringing up sex with your psychiatrist is often magnified when your sexuality has been stigmatized by society or medical providers in the past.
Your hesitation makes sense. Not all psychiatrists have received sexuality specific training. Very often, trained sex therapists deal with undoing the traumatic work other professionals have done poorly. Some professionals may acknowledge their lack of training around sexuality specific issue, while others may attempt to get by using their other expertise and have good intentions. However, the psychological damage of misinformation and / or shame may already be done. Although psychiatrists are professionals and experts on mental health, they can make mistakes. No psychiatrist is an expert on every topic. Sexuality is an often overlooked aspect of human development.
Examples of common misinformation and/or shame producing responses to sexuality:
- Normalizing that sex hurts for cisgender females
- Painful sex is not normal. Whenever anyone experiences a stabbing, burning, or shooting pain during sex, they should stop. Providers should help clients/patients differentiate between discomfort and pain during sex. Often when a female has not had adequate foreplay prepping her vagina for penetration, she may experience initial discomfort during penetrative intercourse. Pain during sex may be indicative of a pain disorder that can require pelvic floor physiotherapy and psychosexual treatment
- Praising a male who reports taking too long to orgasm
- Delayed ejaculation is a real problem for some men. The myth that lasting a long time and prolonging sex as a good thing minimizes that this creates distress for him and his partner. People take the inability or difficulty to orgasm personally as a measure of their attractiveness and can feel broken if they are not able
- Assessing for limited experience and common anxiety impacting maintaining erections rather than writing the quick-fix prescription for Cialis or Viagra
- Mislabeling kink, infidelity, or non-heterosexual orientations as a sex compulsion
- Addictive sexual compulsivity looks a lot different than healthy safe, consensual sexuality
- Minimizing the marginalization you have felt from society for your sexuality
- Psychiatrists who may not share the issue you face with you with little exposure to the lived experiences of those who do may not acknowledge their privilege in society. This minimization can mimic discrimination felt in your daily life or contribute to re-traumatization.
- Over-focusing on your sexuality when you were not distressed about your sexuality
- Psychiatrists do have a responsibility to help you explore other areas of your life that may be contributing to your mental health issues. However, you are the expert on your life. If you have tried individual therapy with a sex positive therapist to confront issues that your sexuality has brought up for you and still seem to have the symptoms of depression as before, it is likely your brain chemistry and you could use the help of medication to assist in treatment.
- Admit they have never worked with someone like you before and ask you to teach them about your sexual dysfunction, type of relationship, sexual practice, or lifestyle
- Psychiatrists are ethically responsible to seek additional education or resources on the issue, seek supervision from an expert when working with a new issue. They may acknowledge their lack of specific training and give you an option to help you find a referral to someone who is better trained on the topic. Continuing to provide you services for an issue they are not the expert on when there are providers better suited for you and are available is unethical. Acknowledging their limitations to you AND seeking supervision to guide them as they guide you is common. With that being said, You, as the client/patient, are not responsible for teaching them in a way that will distract from the treatment you signed up for.
Most psychiatrists will have the factual, reproductive information that doctors are expected to know, but very little training around sexual trauma, sexual compulsion, sexual functioning (painful intercourse, premature ejaculation) and alternative lifestyles of sexuality. Including but not limited to kink, non-monogamy, queer gender identities, fetishes, and sex work. Some psychiatrists with many years of experience may have been trained when the diagnostic statistical manual indicated that any BDSM indicated deviance from what normal psychological presentations. Psychiatrists who have kept up with recent literature know that any of these lifestyles does not indicate a problem unless the patient comes in saying this lifestyle is a problem for them.
Ideas for feeling out your psychiatrist’s ability to handle sexuality
- What they say on their website about their areas of expertise
- How they describe themselves to you on the telephone
- Where the psychiatrist trained and / or currently works
- Look for cues around your psychiatrist’s office
- Rainbow ally buttons or stickers indicating gay affirming practices
- Reading material on sexuality issues
- Paperwork that’s inclusive
- Blank lines to indicate gender and sexual orientation instead of checked boxes to make you force choose show that your psychiatrist or the agency has given thought to how exclusive some forms can be
- Non-heteronormative language
- They do not assume the gender or sex of partners you are interested in
- They ask are you attracted to men, women, or both
- They discuss different types of sexual activity, not assume sex only means penis in vagina intercourse
- They acknowledge FetLife as a healthy social support for exploring kink
- They give you permission to talk about sexuality.
- This may look like an open-ended question around sex / sexuality
- Guided sexual history assessment questions
- They ask you about sexual satisfaction, pleasure, and other positives associated with sex instead of only talking to you about risky sex practices that may lead to unwanted pregnancy or sexually transmitted infections
- They follow your lead on opening up about more sensitive issues pertinent to sexuality at a pacing that is comfortable to you
- Red flags:
- The psychiatrist turns bright red when talking asking you questions about your sexuality
- Using the word abnormal or pathological to describe your sexuality
- Telling you that you are in a phase
- Seems clueless about the topic, and doesn’t ask follow up questions
- Reporting their own bias and trying to lead you to choose a lifestyle that fits their bias
- They urge you to share more details about your sexuality than feels right for you
If you do not feel comfortable asserting sex into your appointment and your psychiatrist does not bring up anything sexual as an opening to the conversation, you may not have the right psychiatrist for you. The Center for Growth / Sex Therapy in Philadelphia offers a sex-positive environment for therapy and psychiatry services that can help you find the right level of treatment for whatever your presenting problem is.