Sex in the Therapy Room: The Training Gap No One Talks About

Sex is everywhere in the therapy room.

It shows up dressed as anxiety, depression, trauma responses, relationship conflict, shame, compulsive behaviors, identity exploration, medical concerns, and power dynamics. And yet, for something so central to human experience, sexuality remains one of the least formally taught areas in clinical education.

Most therapists leave graduate school highly trained to assess risk, diagnose disorders, conceptualize cases, and apply evidence-based interventions, but far less prepared to talk about sex with confidence, clarity, and clinical grounding.

This isn’t a personal failure. It’s a systemic one.

What Most Graduate Programs Teach (and Don’t)

Across counseling, social work, psychology, and marriage and family therapy programs, education on human sexuality is typically limited or entirely absent. Research examining graduate training consistently finds that only a small percentage of programs require a dedicated course in human sexuality, with estimates ranging between 11–18%. When these courses do exist, they are often offered as electives rather than core requirements, meaning many clinicians graduate without ever engaging in structured training on sexual development, sexual functioning, desire, or sexual diversity (Leiblum & Taylor, 2000; Coleman et al., 2013).

As a result, many clinicians enter practice able to diagnose mood disorders and treat trauma, yet unsure how to differentiate normal fluctuations in desire from dysfunction, uncomfortable taking a sexual history, or uncertain how to respond when clients raise concerns about intimacy, arousal, or identity. Sexuality becomes something clinicians know is important, but don’t feel adequately prepared to address.

The Cost of Avoidance (For Clients and Clinicians)

When clinicians lack training around sex and sexuality, avoidance often fills the gap, not because therapists don’t care, but because they don’t feel equipped. Research supports this pattern. In a national survey of practicing psychologists, nearly 90% reported that clients regularly bring sexual concerns into therapy, yet only about 35% felt competent addressing them. Roughly half acknowledged actively avoiding sexual topics due to discomfort, uncertainty, or insufficient training (Wincze & Carey, 1995).

The result is that clients often receive unspoken messages: that sexual concerns are inappropriate for therapy, not clinically relevant, or reflective of personal failure rather than contextual or relational factors. For clients already carrying shame, trauma, cultural stigma, or identity-based marginalization, these messages can be especially silencing.

Clinicians, meanwhile, may feel anxious when sexual material arises, overly cautious about ethical boundaries, or unsure how to stay clinically grounded without becoming detached or dismissive. Rather than protecting the therapeutic relationship, this tension can quietly erode it.

Sexual Health Is Mental Health

The World Health Organization defines sexual health as a state of physical, emotional, mental, and social well-being in relation to sexuality, not simply the absence of dysfunction (WHO, 2006). This framing matters, because sexual functioning, desire, identity, and expression are deeply intertwined with many of the very concerns clients seek therapy for.

Research consistently demonstrates that sexual satisfaction is closely linked to relationship satisfaction and attachment security (Byers, 2005). Trauma survivors frequently experience changes in arousal, desire, avoidance, or pain related to nervous system dysregulation (Seng et al., 2011). Mood disorders such as depression and anxiety are strongly associated with shifts in libido, sexual satisfaction, and body image (Clayton et al., 2016). Medical conditions and commonly prescribed medications, including SSRIs, hormonal treatments, and chronic pain interventions, can significantly impact sexual functioning (Montejo et al., 2018).

Ignoring sexuality doesn’t make therapy safer or more ethical. It makes it incomplete.

Ethical practice is not about avoiding sexual topics, it’s about engaging them thoughtfully, clinically, and within appropriate scope.

Why Continuing Education Matters

Because most clinicians did not receive adequate foundational training, continuing education becomes a necessary bridge. This isn’t about turning every therapist into a sex therapist. It’s about ensuring clinicians have the competence to remain present when sexual concerns arise, use accurate and non-judgmental language, recognize what falls within scope, and make appropriate referrals when it does not.

Research indicates that clinicians who receive targeted education in sexual health report increased comfort discussing sexual topics, reduced avoidance behaviors, greater confidence in assessment, and improved referral practices (Heiman et al., 2011; Brotto et al., 2016). In other words, education doesn’t blur boundaries, it strengthens them.

This is about competence, not specialization.

You don’t need to know everything about sex.
You do need to know how to stay present when it comes up.

Moving the Field Forward

If we want to reduce shame, improve clinical outcomes, and provide truly holistic care, we have to stop treating sexuality as a fringe topic or a liability to manage. It is a core part of being human, and therefore a core part of mental health care.

The gap in education around sex and sexuality is not a reflection of clinicians’ values or intentions. It is a reflection of how our training systems were built. And it is a gap we can choose to address, thoughtfully, ethically, and with humility.

Because when clinicians feel equipped, clients feel safer.
And when clients feel safer, deeper work becomes possible.

Looking to deepen your understanding of sexual wellness and its role in ethical, effective therapy? Join us for upcoming trainings or reach out to consult with Kristin Trudeau, AASECT-Certified Sex Therapist.