Diagnosing Sexual Disorders
Your new client appears nervous as she sits down on your couch. After you go over some introductory thoughts, you ask her what brings her in. She responds that her OB-GYN doctor recommended that she would see therapist for symptoms of anxiety and depression. Nothing unusual, you think to yourself, as a therapist, you encounter such cases every week, and continue to listen to her story.
As she transitions to tell you that she has not had sex with her husband for months now, or when she does, she experiences stabbing pain, anxiety and a feeling of “wanting to escape” from the experience, you start experiencing a sense of ambivalence in yourself. Will you be able to help this client? Do you have enough training to ethically justify not referring her out? Or do you perhaps live in an area where there are no specialists for her to see? What is really the problem she is dealing with?
Whether you are a psychologist, a counselor or a marriage and family therapist, you will, at some point, encounter the need for continuing education on sexual disorders. As we invite you to consider learning more about sexual disorders and intimacy problems, we have put together a check-list of pointers in providing effective therapy for sexual problems. Years of experience in counseling, therapy, mentoring, supervision, and case consultation, have helped us to illustrate some of the key components of providing ethical and effective services to patients with sexual issues:
Can you check these boxes in your own work with clients?
- Thorough assessment
- Hearing their story
- Good problem definition
- Keeping a relational focus
- Selecting a working model
- Choosing an ethical model of intervention
While this is not a complete list, and it must be followed by foundational components like up-to-date, excellent continuing education and good therapist self-care; it can provide a starting point for therapists interested in this field. Yet, at the end of the day, there is no shortcut for being the kind of person it takes to do this work and having excellent foundational information to build on.
Thorough Assessment- The Right Start
When a client first presents with a sexual issue, you immediately begin a thorough assessment by hearing their story.
- What do they see as the problem?
- What do they see as the context, and/or development of the problem?
- What have they already tried to address the problem?
- What is distressing/ bad/ unwanted for them about this problem?
- How does this problem affect their functioning, quality of life, relationships?
How the client defines the problem is often rather different than how a professional defines the problem. In psychology, we are trained to fit data we receive from clients into categories that help us define a path forward. What seems big and overwhelming for a client will be put into a diagnostic terms by the clinician and associated with expected treatment outcomes. However, when it comes to sexual issues, this is process is not always so straightforward.
Nosology- Finding the Right Words
Nosology, the science of identifying and describing problems, is a theoretical and political discussion in the field of sex therapy. In most of medicine, etiology dictates diagnosis (if you’re infected by the influenza virus, you have the flu). In sex therapy, etiology is often unknown, or complex. A competent counselor, marriage and family therapist, social worker, psychologist, or other therapy professional will ensure they are up-to-date in current nosology and by doing so, they will aim at providing ethical care for their clients.
Problem definition is not just a theoretical discussion in professional circles, it’s also theoretical in your office. Each clinician needs to decide if they are going to follow a defined nosology (ICD-11, DSM-5, ICSM) or an entirely different angle, such as a narrative approach to problem definition.
Consider whether a formal diagnosis is indeed justified: Are you really treating a disorder or a dysfunction or are you perhaps only treating the client’s distress about this problem?
Relational Context- Relationship to Self
Good practice involves keeping the client and the problem in a strong relational context. Remembering that people and problems do not exist in a vacuum is critical, especially when doing sex therapy. It can even be argued that solo sexual practices are still relational, they involve an individual’s relationship to themselves and their body.
Pursuing continuing education that attends to models of systemic and relational focuses will help develop this lens. Failure to keep the client and problem in a relational context often results in doing inadvertent harm at worst and strengthening the entrenchment of the problem at best.
Michael Sytsma from Sexualis Veritas was a contributor this post.