How do I talk to a psychiatrist about sex?
Sam replies:I'm turning 18 soon and I have a myriad of problems regarding sexuality. I have a few guesses as to their origins, and it's incredibly complicated with too many different factors. it's something very complicated that could only be managed with years worth of mental health counseling, but so much as talking about it in real life (as opposed to texts) sends me into panic attacks. I feel horrible, scared and shameful in a way i can't describe, and it always ends up with me cutting myself to get some relief, and maybe some "punishment". I also feel very embarrassed because I don't think I "look" like someone who's sexual. I don't identify as a girl yet most people view me as a very innocent, quiet girly girl and I feel like that image is severely contrasted with how I feel. like someone like me being sexual is shocking, disgusting, scary. I feel as if it would be easier to talk about if I "looked" like a "sexual" person, whatever that means. So how do you recommend I discuss the matter with a mental health professional without getting a panic attack and feeling like my appearance does not "fit" someone who feels the way I do?
You've asked a lot of big questions here, which means I have some big answers for you. This is going to take a minute, so you may want to find somewhere comfy to settle in while you read.
Before we get into anything else, I want to say that if you're regularly self-harming, or fear that you might, then I think getting safe first by accessing mental health supports is your best next step. If therapy feels too daunting or isn't accessible to you right away, one starting place is the NAMI help line. You can also use a tool like this list of alternatives or Kate Bornstein's Hello, Cruel World -- which you can get as a book from your library or local bookseller, or as an app--as a means of looking after yourself when mental healthcare is harder to access.
Let's start with some basics around broaching sex in therapy. One of my biggest tips when there's a topic — be it sex or something else — that you're anxious to bring up with a therapist is to be upfront with them about what's going on. There can be a temptation to be a "good" client in therapy; responding well to techniques, following the direction the therapist takes the sessions, and avoiding bringing up issues that feel awkward or like they're "too much." In other words, you can end up hiding all the messy, raw pieces of yourself that you're in therapy to care for in the first place.
I encourage people to think of therapy is being collaborative, like building a house, rather than evaluative, like submitting homework for a grade. Yes, therapy often involves digging into issues to work out what might be causing them. But therapy that stops there is unlikely to do much in terms of long term benefits. It'd be like going, ”Ah ha, this house has termites!” and leaving it at that instead of calling an exterminator. The more active a role you take in addressing the underlying causes, the more likely you are to get positive results.
That still leaves the issue of bringing up a topic that makes you panic. One of the simplest solutions I've found is to write it out in a note and give it to them. If you have a way to text or message your therapist, you could also send the information to them that way in advance of your session. Doing that can make you feel less put on the spot and gives you a chance to articulate complicated or tough feelings at your own pace. Speaking of pace, when you're talking in-person about sex with a therapist, you're allowed to ask for moments to think, or for the space to just think out loud uninterrupted for a bit. That can help you feel a little calmer because it lessens the feeling that you have to have a perfectly formed answer right now.
Since you know talking about sex gives you panic attacks, I would communicate that to your therapist ahead of time (this is something else that could go in a note you give them). That helps them be prepared to support you while you're opening up to them about this topic. The two of you can also talk ahead of time about what calming techniques you'll switch to if the conversation starts the panic cycle in your brain and body.
Part of why I chose this question is because you are far from the first person who's told us they’re anxious talking about sex with a therapist. I think a large part of that pattern is due to how sex is still a very taboo topic for a lot of people. We're not encouraged to talk about it openly, so even when we want to bring it up, or know we need to, we have no idea where to start. I actually think the advice Heather lays out here for talking about sex with a partner still applies when talking about sex with a therapist. There are also a few other things I encourage people to remember when talking with therapists about sex:
- A common concern is that sex is an inappropriate topic for therapy. But therapy is exactly the place to bring up complex feelings about topics you bring up in other spaces and, broadly speaking, there aren't really topics that are inappropriate to raise with a therapist, sparing the therapist’s personal life.
- While therapists haven't heard everything, the average one has had a massive range of topics arise with clients. Given how many mental health issues intersect with sex in some way — including troubles with libido, relationships, and self-esteem — odds are extremely low that you're the first person to bring sex up.
- You can use sex-positivity or experience with sexual topics as a selection criteria when choosing a therapist. While most therapists have had sexual topics come up, that doesn't mean every therapist will have the skillset or therapeutic framework to address them effectively. Looking for therapists who include "sex positive" in their bios, or who list themselves as working with queer, kinky, or polyamorous populations is a good starting place, as people with those backgrounds are likely to be more experienced discussing sex-related topics. Some therapists even have specific sex therapy training or credentials.
- If part of your feelings about sex are tied up in sexual trauma, look for a counselor who specializes in working with survivors.
- You're always allowed to end a therapeutic relationship. If your therapist makes you feel ashamed for being sexual, that's a sign they're not a good fit for you (or probably anyone!) and you'll want to see what other options are available.
I also want touch on your comment about how you don't feel like a girl but you're still read as one by other people. You don't give a ton of details as to how you do identify, but I want to encourage you to make what space you can to explore what gender expression and identity does feel right to you. The gender gear guide from our Trans Summer School series can help with that, and I also love the identity-exploring activities laid out in the Gender Quest Workbook and the Gender Identity Workbook for Teens. If you end up needing more support and resources during that process, you're always welcome to come to our direct services for help.
At the heart of your question is an idea that needs challenging; that there's a way “sexual people” look. To start, "sexual" as a term can mean a lot of things. If we're talking about people who have sex or desire sex, that can look like anyone: nerds, jocks, goths, parents, grandparents, sex workers, pastors, kindergarten teachers, rock stars, the list is endless.
Even if we're only talking about people who are having a ton of sex, those people can still look any possible way. We have these cultural ideas that someone who's having sex all the time will dress in ways we consider provocative. Some of that comes from the media we consume, but it also comes from the fact that it's comforting to think we can tell everything there is to know about a person just by looking at them. But a person who's having sex every night may prefer a maxi dress or overalls, and a person who's not having sex or isn't interested in ever having it may love a mini skirt or going shirtless.
You may be nodding along and going, "Yes, of course!" But there's a big difference between knowing something and internalizing it, and it sounds like that might be the part of all this that's tripping you up. When we're trying to internalize more positive or complex messages about sex, there are some topics it helps to unpack. You can work through these on your own, or with the help of your therapist:
- What things influence your ideas about sex? That could be the sexual values of your culture, family, faith, or your friend group. It could be the media you consume and what messages it sends about the "right" or "normal" ways of being sexual. How do you feel about those messages and values? Are there parts of them you want to move past or hold on to? The answers to those questions can lay a foundation for how you want to embody your sexuality.
- What things influence your ideas about sex as it relates to you, specifically? Do you have sexual experiences in your past — be they traumatic, wonderful, or somewhere in between — that shaped how you think of yourself as a sexual being? Have those experiences left you with certain "gut reactions" towards the thought of yourself in sexual situations? Have people talked about you like you're the exception to some sexual norm? That could be statements like, ”You're not a slut like other girls, you're a nice girl,” or, "Wow, I can't believe anyone would do [insert sexual thing you've done here]."
- What about your feelings about your sexual orientation, gender identity, or both? Because there's still so much stereotyping around sexual behavior and gender, some people feel as if they're not sexually behaving the "right" way for their gender; you see this with men who are worried because they have little to no interest in sex, or women who are freaking out because they think their sex drive is too high. Similar stereotypes pop up around sexual orientation, with the assumption that because someone is gay/bi/pan/etc., their sexual desire will look a certain way. All of this can trip people up who are working out their gender identity. For example, a trans masculine person who experiences little sexual desire may worry that's somehow a sign that he isn't "really" masculine. Since you mention your gender not being what people think it is, it's worth asking whether any of those feelings contribute to how you view yourself sexually.
- In a perfect world, what would your sex life look like? That could include things what kinds of relationships--casual, monogamous, polyamorous-- you'd want to be sexual in, what gender(s) of partner you want to be with, what kinds of things you'd like to try with partners, what fantasies you want to explore, even what ways of dressing or expressing yourself make you feel sexy and confident. Envisioning the sex life you want for yourself gives you a positive goal to work towards, rather than putting your focus solely on what you want to avoid.
I hope that all of this has given you some starting places for addressing those complex feelings about sex, both with a therapist and with yourself. Working through our sexual pasts can be emotionally rough, and you deserve all the support you can get to help you with that process.
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