Every therapist encounters, at least occasionally, a client seeking help with sexual issues of one ilk or another. Typically, these individuals are either overtly or covertly worried about too much sex, not enough sex, no sex, strange sex, addictive sex, cheating sex, bad sex (whatever “bad” means), etc. Sometimes these concerns are their primary presenting issue, but usually not. More often, sexual issues lurk in the background, hiding behind depression, anxiety, fear of rejection, shame, and similar problems. In such cases, a client’s sexual concerns might only come to light while exploring the client’s self-esteem, failed relationships, substance abuse, unresolved early-life trauma, mood disorders, etc.
Recognizing this, I find it useful to incorporate a few very basic sex-related questions into the initial assessment with every client. Unfortunately, many therapists and clients are uncomfortable discussing sexual issues. As such, it is important for any initial queries to sound as neutral as possible. A few non-threatening questions I typically ask are:
- Do you have any concerns about your current or past sexual or romantic behaviors?
- Has anyone ever expressed concern about your sexual or romantic behaviors?
- Is there anything about your sexual or romantic life that feels shameful to you or that you work to keep secret?
Asking these simple, straightforward questions generally ensures that a client’s important sexual concerns (issues that might underlie and drive more obvious problems like depression and anxiety) aren’t overlooked. By posing queries and nonjudgmentally following up as indicated, we give clients permission to talk about their sex life and the ways in which it might be affecting them. We let them know that it’s OK (safe) to discuss their sex life in treatment, however much shame they may be feeling about it.
Among the sexual issues commonly encountered is a client’s desire for (and shame/anxiety about) non-traditional forms of sex, including kinks, fetishes, and paraphilias. At this point, some readers may be wondering exactly what I mean when I use the words kink, fetish, and paraphilia. And with good reason, because if you search the internet you’ll find a wide variety of definitions with quite a lot of overlap.
In my work, I tend to define kinks as nontraditional sexual behaviors that people sometimes use to spice things up, but that they can take or leave depending on their partner, their mood, etc. Fetishes are nontraditional sexual interests or behaviors (kinks) that are, for a particular individual, a deep and abiding (and possibly even necessary) element of sexual arousal and activity. Paraphilias are fetishes that have escalated in ways that have resulted in negative life consequences.
A kink, a fetish, and a paraphilia can involve the same behavior, but the role that behavior plays and the effects it has can be very different depending on the person. Consider as an analogy the difference between a casual drinker, a heavy drinker, and an alcoholic. The basic behavior, consuming alcohol, is the same, but the underpinnings, impact, and long-term effects are quite different depending on the person. Moreover, it is only when the behavior is taken to an extreme that results in negative life consequences that it’s viewed as a disorder. For instance, the DSM-5 says that for a kink or fetish to qualify as a paraphilic disorder, the arousal pattern/behavior must create “significant distress or impairment in social, occupational, or other important areas of functioning.”