‍Do you explore the themes of Sex and Sexuality in your patients?

In therapy, we as therapists often avoid this topic, for various reasons. Likewise, the patient may not provide sufficient information unless they present with a concern directly related to sexuality.

Yet it is precisely this domain that opens access to the deepest aspects of the individual’s inner world, as it is not only a sphere of symptoms or interpersonal conflict, but also one of the fundamental foundations of subjective well-being.

Sexual behavior, desire, and motivation belong to the fundamental, innate needs of the human being—those with which we are born. 

For this reason, without exploring this domain, it is not possible to fully understand the personality or to support its development.

In clinical practice, sexuality is not limited to questions of behavior or functioning. It also involves:

- the capacity to fall in love

- the ability to tolerate intimacy

- the integration of tenderness and erotic desire within stable relationships.

For this reason, exploring a patient’s sexual life should include not only actual sexual behavior, fantasies, and fears, but also the capacity to form deep loving relationships with a person who is also a sexual partner.

For example, a patient may describe an active sexual life with casual partners, while at the same time reporting a loss of sexual desire in the relationship with her husband, whom she loves.

Another patient, by contrast, may be capable of falling in love and forming emotionally meaningful relationships, yet avoid sexual intimacy, experiencing anxiety or a loss of arousal precisely when the relationship becomes more intimate.

In such cases, sexual symptoms reflect not so much a dysfunction as a conflict involving intimacy, aggression, guilt, and dependency.

In another clinical situation, a patient may demonstrate intense sexual arousal only in fantasies involving dominance, humiliation, or distance, while sexuality becomes inhibited in real relationships with a partner.

In other instances, sexuality may remain active but lack emotional involvement, accompanied by difficulties in forming stable attachment.

These differences help determine whether love and sexuality are integrated or remain split.

This distinction between integration and splitting of love and sexuality has important diagnostic significance.

The capacity to fall in love and to maintain stable love relations is a fundamental expression of the degree of maturity of object relations, and, not surprisingly, the more severe the personality disorder, the more limited these emotional capabilities. 

The combined analysis of the capacity for a love relation and of the nature and degree of difficulties in the realm of sexual behavior permits, in practice, differentiation of a broad spectrum of sexual pathology, ranging, at one extreme, from the sexual pathology of patients with severe antisocial behavior and antisocial personality proper to, at the other extreme, a flexible and broad sexual functioning in the context of a stable, deep love relationship with a specific partner. 

Patients with a relatively integrated personality organization may report some degree of sexual inhibition—difficulty reaching orgasm, reduced arousal, or episodic impotence—while still maintaining the capacity for deep loving relationships.

By contrast, in more severe disturbances, sexual behavior may become chaotic, impulsive, or devoid of emotional attachment, with sexuality used to regulate self-esteem, aggression, or fears of abandonment.

In other cases, near-complete sexual inhibition may be observed, accompanied by fear of closeness, avoidance of intimacy, and difficulty forming stable relationships.

(c) Yuliia Holopiorova,

Ukrainian Association of Transference-Focused Psychotherapy

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