The Intersection of Therapy and Medicine: Staying Within Scope of Practice

Our bodies, our minds, and our relationships are all interlinked. You can’t pull on one thread without pulling on all the others.

However, when it comes to the body part of the equation, a lot of therapists start to feel a bit…antsy. And understandably so! Most therapists had no training in sex, pleasure, or the physiology of arousal. And going outside of our scope of practice is a real concern.

If you’ve been reading this article series, you know I encourage all therapists to bring up sex in therapy, early in treatment, with all clients. But once you open the topic, you’ll also need to have some skill in following through with strong conversations and useful interventions for sex-related issues. So, what happens when your client has a sex issue that involves the intersection of physical function, emotional issues, and relational dynamics?

First, let me say that almost all sex issues involve the intersection of physical systems, emotional systems, and relational context. Just because your client’s issue might appear to be “just desire” doesn’t mean physiology isn’t important. In fact, it very much is. So, the bad new is that working with sex issues by definition involves body stuff.

Some therapists solve the problem by referring all sex issues to specialists–usually, AASECT- certified sex therapists like me. That’s not a terrible strategy, but as you probably know by now, I think you can keep almost all of those clients, and get a lot more as well! In my opinion, generalist therapists can easily learn to handle the vast majority of common sex issues, which is a good thing, because there aren’t nearly enough sex therapists to handle all the sex issues in the world. After all, everyone experiences a sex issue now and then.

Another strategy is to refer the medical concerns to the client’s primary care physician. Unfortunately, there are pitfalls there too. The medical system can be complicated and confusing, and not all providers are great at having non-judgmental conversations about sex. Lots of physicians had little to no training about sex, and instead had a focus on reproduction which is not at all the same topic. As a result, your clients would most likely benefit from some skilled and compassionate support in navigating the system.

In this article, I’m going to tackle two common areas where therapy, physiology, and medicine intersect: sex pain and erectile dysfunction. I’ll explain what you can do to ensure that your clients get the care they need, without going outside of your scope of practice.

Part One: Sex Pain

Elena is standing at the sink, doing dishes before bed. Struck by the cozy hominess of the moment, her husband, Manuel, puts a hand on her shoulder and tries to kiss her neck. She shudders away from his touch, pushing his arm off her shoulder.

Think about all the pain that’s crystallized in that moment. Elena is deeply stressed. She can’t enjoy a simple moment of touch, because she’s afraid it will inevitably lead to other forms of intimacy that she doesn’t want, and she doesn’t know how to say no, or believes that she isn’t allowed to ‘stop the train’ of an escalating sexual interaction once it begins. Meanwhile, Manuel feels hurt and rejected, and he doesn’t understand where things went wrong.

We have two people who are touch-starved, lonely and confused, living in a marriage with no physical intimacy. To understand what went wrong, we have to go back in time. We have to unravel a dynamic that’s developed over years and find the problem at the very core. Neither of these partners need be seen as a villain. They can both be loving people who are doing their very best, both deeply longing for physical and sexual contact with one another, yet still find themselves in this situation.

Elena is experiencing an aversion to sexual touch. This is an anxiety response based on past experience. Those might include a history of trauma, but not necessarily. In fact, very often, sexual aversion starts with undisclosed sex pain.

When someone experiences sex pain but isn’t able to bring themselves to express that to their partner, it sets both of them up for a world of trouble. Inside, they’re screaming “no!” But they can’t bring themselves to say it out loud–whether out of a fear of hurting their partner’s feelings, a belief that they are obligated to provide sex, or whatever other combination of factors. This results in a kind of trauma that doesn’t really have a perpetrator (unless, perhaps, you consider the perpetrator to be cultural beliefs about sex).

Pain is your body’s way of saying “pump the brakes.” It’s non-negotiable. And when we push past it, we create the circumstances for a sexual aversion to develop. Unraveling all of this takes time, and both partners will have been deeply affected. It’s much better to catch sex pain early, before it builds into an aversion dynamic like this one.

Quick interventions for sex pain 

• Ask! My Will Lily brief assessment tool can provide you with the exact wording I use; you can find it here if you haven’t already checked it out. I use it with all my clients. 
• Normalize pain-free sex. Unfortunately, all too often, people with vaginas assume that some amount of pain with sex is normal, and that they should just grin and bear it. It’s important that your clients know that pain with sex is never something they should just put up with. If it doesn’t resolve quickly, it will create complicated problems down the road. 
• Provide or recommend some high-quality lubricant. One of the most common causes of sex pain is a lack of lubrication. This is especially common as we age. I always keep high-quality lubricant samples in my office, and I give it to clients who describe mild sex pain that feels to them like it is caused by friction. If they feel safe and comfortable trying it out with their partner, this intervention has the potential to quickly eliminate one type of sex pain. If it doesn’t work, I have ruled out the easiest thing, and have more information about how to effectively help moving forward. For more information about high quality lubricants, refer to this excellent article.
  
• Offer hope. There are many, many potential causes of sex pain–far too many to get into right now. (That’s the kind of in-depth material I cover in my intensive online course, Assessing and Treating Sex Issues in Psychotherapy.) However, with the right specialists to help with the medical angle, and an appropriate course of therapy to strengthen relational skills and build flexibility, most sex pain can be resolved. Your clients are not broken, and with the right help, they will be able to experience pain-free sex. That knowledge can be hugely motivating, so make sure your clients know that there is hope. 
• Refer to the right medical professional, and do so promptly. Here is my rundown on types of medical professional and the pros and cons to referring your sex pain client to them:
• Primary care physician: most PCPs didn’t have adequate training in sex issues to be much help; their training still mostly focuses on reproductive health, not sexual health. If your client has to go to their PCP to get a referral to a specialist, let them know what kind of specialist they should seek out, in case their PCP doesn’t know.
• Ob/gyn: see above. There is such a thing as an ob/gyn with a specialization in sexual health or sexual medicine, in which case great. But otherwise, I would skip this specialist, or at least, if the pain doesn’t clear up, don’t give up and instead continue on to another professional.
• Pelvic floor physical therapist: for people of all genders, the most accessible and affordable specialist who is most likely to provide an accurate diagnosis and treatment of sex-related pain is a pelvic floor PT. The pelvic floor is not the only cause of sex pain, but it is the most common, and if there is also something else going on, they will discover that too and make a further referral.
• Sexual medicine specialist: these can be tough to find. Look for a practice in your area that advertises working with sex issues. They might have a surgeon like an ob/gyn, and a fleet of nurse practitioners, or a group of allied health professionals, or they might be one person in a private practice. Call them up and ask what they do.
• Vulvar pain specialist: this is a specialist that can help with external vulvar pain, which is a complicated topic and can be tough to treat. It often co-occurs with pelvic floor issues, so starting with a pelvic floor PT is not a bad strategy. 
• Urologist: When a client with a penis experiences sex pain, they will need either a urologist, a pelvic floor PT, a sexual medicine specialist, or a combination. If there is a sexual medicine specialist in your region, I’d start there. A pelvic floor PT is also a terrific bet. Interestingly, sort of similar to an ob/gyn, a urologist might or might not know much about treating sex pain. Sometimes what appears to be an infected or inflamed prostate (prostatitis) turns out to actually be high tone pelvic floor disorder (and we’re back to the pelvic floor PT). I have no objection to consulting a urologist; just don’t stop there if they have nothing helpful to add.

Part Two: Erectile Dysfunction

Let’s envision a therapy room. Ridhi and Hugh, a couple in their early 50s, have come in today to discuss Ridhi’s growing sense of insecurity. Hugh hasn’t been initiating sex in the way she’s used to, and she’s been afraid that he’s no longer attracted to her.

The therapist digs into the issue, and learns that from Hugh’s perspective, he’s been worried because he hasn’t been having erections that last as long or get as hard as he used to. He’s even stopped having erections in the morning. He’s been feeling insecure, too, and he’s stopped initiating sex because he’s worried that he’ll be embarrassed or hurt Ridhi’s feelings if he loses his erection partway through.

Having checked their assumptions and seen each other’s vulnerability, Ridhi and Hugh feel much closer. They leave feeling seen and loved by one another, and with a new resolve to try connecting intimately. This is good therapy; the therapist in this scenario did a great job.

However, they missed a really important opportunity: they didn’t follow up on the medical aspect of Hugh’s erectile changes. The data is clear: Changes in erectile capacity very often precede a heart attack by three to five years.

This is serious stuff. This information could quite literally save your client’s life.

Unfortunately, these stark facts are far from common knowledge. I’ve found that most people assume that loss of erection is a normal part of aging. While they may be unhappy about the change, they won’t necessarily see it as something that necessitates medical investigation.

That’s why I think it’s so important to ask about physical signs of arousal (it’s one of the questions in my Will Lily assessment). If they report a change in erectile function, I explain the heart health-erection connection, and strongly encourage them to schedule a visit to a cardiologist, or at least a stress test with their physician.

I know that asking so directly about physical signs of arousal can feel uncomfortable–even more so than general questions about sex. Here’s what I do to help manage my clients’ discomfort (and my own) with such specific questions:

• Signal my own comfort through my tone and body language. It’s amazing how much of a difference projecting your own comfort and confidence can make. It shows your client that you’re ready to receive whatever they have to say, and that they don’t have to worry about making you uncomfortable. A lot of our clients’ anxiety about discussing sex comes from the fear that they’ll put us off with too much information. Showing that you can handle it can go a long way towards putting those fears to rest. I’m sure you have your own strategies for accessing an internal sense of confidence and ease. For myself, I like to breathe deep and plant my feet firmly on the ground, but I encourage you to do whatever works for you. 
• Know why I’m asking. With quite specific questions, it can help you feel confident when you know that there’s a good reason behind every question. When you’re asking about physical signs of arousal (like hardness, wetness, a full body feeling of being turned on), you are asking if the body systems involved in arousal seem to be working. Many body systems are involved in arousal, making changes in erectile function an early warning sign of multiple physiologic issues, some of which may progress, and eventually manifest in medical problems that cannot be ignored. If you know why you’re asking a question, if your client expresses discomfort you can explain your purpose, so they know you aren’t just prying.
• Get consent to ask. Before I ask any of the very specific questions about sex in my brief assessment, I ask for permission to do so: “Would it be ok with you if I ask some pretty specific questions about sex that will help give me an idea of what’s going on?” I also let them know that if I ask something they don’t want to answer, they don’t have to. If they say they aren’t comfortable discussing it, I will back off. But I will probably first say “Thank you for letting me know you aren’t comfortable. We don’t have to discuss it. Before we drop the topic entirely, may I tell you why I’m asking? You can still decide not to discuss it.”  
• Frame the medical referral in a non-anxious, positive manner. It is understandably jarring to go to your therapist and hear that you are at risk of having a heart attack. This is another area where my non-anxious presence can really make a difference. I am careful how I frame this news, and I tailor it to each individual client. Here is one way it might sound:. “There is a strong connection between erectile function changes and heart issues; because I care a lot about your health, I want you to know this. My recommendation is that you make an appointment with a cardiologist to rule out heart issues, and then you can just breathe a huge sigh of relief and let it go, and we can focus on helping you experience improved erectile function and more satisfying sex without worrying we are missing something big. What do you think?” If the client says “My primary care doc did bloodwork and it came out fine,” I would respond “Great news! That’s a good start, but isn’t as reassuring as a visit with a cardiologist, or second best would be a stress test.” If my client says “Martha, I’m not going to go to a cardiologist and I’m not going to get a stress test,” I would say, “That’s fine, and of course it’s your choice. I just want you to know of the connection, so you can make the right decision for yourself regarding your health.”

As you reach the end of this article, I hope you’re feeling a little more confident about how to handle scope of practice when sex issues and medical issues intersect. Because sex issues are so sensitive, it’s all too common for people to miss out on receiving the help they need. By acting as an informed advocate and supporter, while making the appropriate medical referrals, you can truly make a difference for your clients.