Sex, sexuality, intimacy

Sex, sexuality, and intimacy is a broad clinical specialty area covering sexual function, sexual identity, gender identity, intimacy difficulties, sexual concerns related to medical or psychological conditions, and the broader psychological dimensions of human sexual experience.

Overview

Sex, sexuality, and intimacy is a broad clinical specialty area encompassing the psychological dimensions of human sexual experience. The field addresses sexual function and dysfunction, sexual identity development, gender identity and expression, intimacy and relationship issues, sexual difficulties related to medical conditions or psychological conditions, sexual trauma recovery, and the broader integration of sexuality into healthy adult life.

The DSM-5-TR addresses sexuality through several diagnostic categories: Sexual Dysfunctions (Female Sexual Interest/Arousal Disorder, Female Orgasmic Disorder, Genito-Pelvic Pain/Penetration Disorder, Male Hypoactive Sexual Desire Disorder, Erectile Disorder, Premature/Early Ejaculation, Delayed Ejaculation, Substance/Medication-Induced Sexual Dysfunction); Gender Dysphoria in children, adolescents, and adults; and Paraphilic Disorders (when paraphilias cause distress or harm). Sexual orientation itself is not pathologized in the DSM-5-TR.

Population data indicate substantial sexual concerns in adults: approximately 30-40% of women and 20-30% of men report at least one sexual concern affecting wellbeing or relationships. Specific concerns vary by life stage — desire concerns and arousal/orgasmic concerns more common in some life stages; erectile concerns more common with aging in men; pain conditions, perimenopausal changes, and intimacy difficulties common across women’s reproductive lifecycle.

Common clinical presentations include: desire discrepancy in couples; erectile dysfunction (psychogenic, medical, or mixed); female sexual interest/arousal concerns; orgasmic difficulties; sexual pain conditions; postpartum and perimenopausal sexual changes; sexual concerns related to chronic illness or medications; sexual trauma recovery; compulsive sexual behaviour (see our sexual addiction page); relationship intimacy difficulties; sexual orientation and identity exploration; gender identity work; and integration of sexuality with religious, cultural, or family-of-origin context.

Effective treatment is available. Sex therapy as a specialized practice combines evidence-based psychological approaches with sexual-health expertise. Coordination with medical providers (urology, gynecology, endocrinology, primary care) is often part of comprehensive care. Recovery and improvement are realistic outcomes for most concerns.

Signs and symptoms

Sexual desire concerns — Reduced or absent sexual interest; desire discrepancy in couples; significant change in desire from baseline.
Sexual arousal difficulties — Difficulty becoming or staying aroused; lubrication or erectile concerns; mismatch between mental and physical arousal.
Orgasmic concerns — Difficulty achieving orgasm; absent or reduced orgasmic experience; premature or delayed ejaculation.
Sexual pain — Painful intercourse, vulvar pain, vaginal pain, pelvic pain, scrotal or penile pain; persistent or recurrent.
Performance anxiety — Anxiety about sexual performance interfering with sexual function; cycle of anxiety, dysfunction, and increased anxiety.
Body image and sexual self-concept — Distress about body affecting sexual experience; sexual self-evaluation difficulties.
Intimacy and connection difficulties — Difficulty with emotional intimacy, vulnerability, or sustained connection; intimacy avoidance.
Sexual orientation and identity exploration — Questions, exploration, or distress about sexual orientation; coming-out considerations.
Gender identity considerations — Gender dysphoria; transition considerations; gender-affirming care.
Sexual trauma impact — Lasting impact of sexual abuse, assault, or coercion on sexual function, intimacy, and identity.

Diagnostic context

The DSM-5-TR Sexual Dysfunctions chapter includes:

Female Sexual Interest/Arousal Disorder (302.72)
Female Orgasmic Disorder (302.73)
Genito-Pelvic Pain/Penetration Disorder (302.76)
Male Hypoactive Sexual Desire Disorder (302.71)
Erectile Disorder (302.72)
Premature (Early) Ejaculation (302.75)
Delayed Ejaculation (302.74)
Substance/Medication-Induced Sexual Dysfunction (291.89, 292.89)
Other Specified or Unspecified Sexual Dysfunction

Each diagnosis requires symptoms persistent for approximately 6 months, occurring in 75-100% of sexual encounters, causing clinically significant distress, and not better explained by another disorder, severe relationship distress, or other significant stressors. Severity specifiers (mild, moderate, severe) and lifelong vs acquired, generalized vs situational specifiers apply.

Gender Dysphoria chapter includes diagnoses for children (302.6), adolescents and adults (302.85). Gender Dysphoria is distinguished from gender variance per se; the diagnosis applies when distress about discrepancy between experienced gender and assigned gender is clinically significant.

Paraphilic Disorders chapter applies when paraphilic interests cause distress, impairment, or harm to others. Paraphilic interests themselves are not necessarily pathological; the disorder requires impact.

Differential diagnosis requires evaluation for medical contributors (cardiovascular disease, diabetes, hormonal dysfunction, neurological conditions, gynecological conditions); medication effects (particularly SSRIs, antipsychotics, blood pressure medications); substance effects; and primary psychiatric conditions (depression, anxiety, trauma) that affect sexual function.

Causes and risk factors

Sexual concerns arise from interaction of biological, psychological, and relational factors:

Biological factors: hormonal status (testosterone, estrogen, thyroid, prolactin); cardiovascular health (vascular function affects arousal); diabetes; neurological conditions; gynecological conditions; medications (SSRIs particularly affect sexual function in 30-70% of users; antihypertensives, antipsychotics, others); aging-related changes; pregnancy and postpartum hormonal changes; perimenopause and menopause.

Psychological factors: mental-health conditions (depression substantially affects sexual function; anxiety, OCD, eating disorders, trauma history); body-image concerns; performance anxiety; sexual self-concept; family-of-origin sexual messaging; religious and cultural frameworks.

Relational factors: relationship distress, communication difficulties, infidelity, mismatched sexual scripts or preferences, pursue-distancer cycles around sexuality, intimacy avoidance.

Trauma history: sexual abuse, intimate partner violence, sexual coercion all affect adult sexual function and intimacy. Recovery work supports sexual reintegration.

Identity factors: sexual orientation development; gender identity; intersection of sexuality with religious upbringing, racial/cultural identity, disability; coming-out and identity-integration processes.

Life-stage factors: adolescent sexual development; young-adult sexuality; partnered sexuality; postpartum changes; perimenopause and menopause; aging and sexuality.

Cultural and structural factors: societal sexual scripts; gendered sexual expectations; LGBTQ+ stigma in some contexts; religious frameworks that produce sexual shame; lack of comprehensive sex education.

Typical treatments

Sex therapy combines evidence-based psychological approaches with sexual-health expertise:

Sex Therapy: specialized clinical practice typically including comprehensive sexual-history assessment, psychoeducation, addressing cognitive and emotional factors, communication skills, behavioural interventions (Sensate Focus), homework assignments, coordination with medical care.

Cognitive behavioural Therapy: addresses cognitive distortions about sexuality, performance anxiety, body-image concerns; effective for many sexual concerns.

Sensate Focus (Masters & Johnson): structured behavioural intervention for sexual dysfunction; emphasis on touch, mindfulness, communication, gradual reintegration of sexual contact.

Mindfulness-based approaches: Mindfulness-Based Sex Therapy (Lori Brotto) — evidence-based for women’s sexual concerns, particularly desire and arousal.

Couples sex therapy: integration of couples therapy and sex therapy for relationship-embedded sexual concerns.

Trauma-focused approaches: for survivors of sexual trauma; integrated with sexual-health work.

Pelvic floor physiotherapy: for sexual pain conditions, postpartum sexual changes, perimenopausal pelvic concerns; coordinates with sex therapy.

Medical interventions: coordination with primary care, urology, gynecology, endocrinology for medical contributors. Medications include PDE-5 inhibitors (sildenafil, tadalafil) for erectile dysfunction; flibanserin and bremelanotide for hypoactive sexual desire disorder in some women; topical estrogens for vaginal symptoms; testosterone replacement when indicated; addressing medication-induced sexual side effects through medication adjustment.

LGBTQ+-affirming sex therapy: specialized practice addressing the distinctive sexual-health needs and identity considerations of LGBTQ+ individuals and couples.

Gender-affirming care coordination: for individuals navigating gender identity, mental-health support coordinates with gender-affirming medical care; specialized clinicians provide gender-affirming therapy.

Treatment of comorbid conditions: depression, anxiety, eating disorders, substance use, trauma all commonly affect sexual function; treating these often improves sexual concerns.

Religious and cultural integration: spiritually integrated sex therapy supports clients integrating their sexuality with religious or cultural frameworks; respectful of diverse worldviews.

When to seek help

Professional support is indicated when:

You are experiencing sexual difficulties (desire, arousal, orgasm, pain) causing distress or affecting your relationship.
You and your partner are experiencing intimacy difficulties or sexual mismatches.
You are working through the impact of sexual trauma.
You are exploring questions about sexual orientation or gender identity.
Medical conditions or medications are affecting your sexual function.
Pregnancy, postpartum, or menopause has substantially changed your sexual experience.
Religious or cultural messaging is affecting your sexual integration.
You are experiencing compulsive sexual behaviour (see our sexual addiction page).

Look for therapists with specific training in sex therapy — credentialing through American Association of Sexuality Educators, Counselors and Therapists (AASECT), or equivalent training. Sex Therapy Canada and provincial sex therapy associations provide directories. Egale Canada for LGBTQ+ resources.

For sexual abuse and trauma support: 1-866-863-0511 (Assaulted Women’s Helpline). For mental-health crisis: 9-8-8 (Suicide Crisis Helpline).

Frequently asked questions

Are sexual concerns mostly psychological or medical?

Often both. Comprehensive evaluation considers medical contributors (cardiovascular, hormonal, medication, gynecological), psychological contributors (mental-health, body image, trauma), and relational contributors. Treatment frequently involves both medical and psychological interventions.

My desire has dropped after starting an antidepressant — what can I do?

SSRIs affect sexual function in 30-70% of users. Options include: discussing with prescriber about dose adjustment, switching to a different antidepressant (bupropion, mirtazapine have less sexual impact), adding an adjunctive medication, addressing the depression itself when it improves often allows discontinuation. Do not discontinue antidepressants abruptly without prescriber consultation.

What is sex therapy?

Sex therapy is talk therapy — there is no physical contact between therapist and client. Sex therapy combines psychological treatment with sexual-health expertise. Sessions involve discussion, education, exploration of sexual concerns, often with structured homework activities to be completed privately or with partners. AASECT-certified or equivalent specialized training.

My partner and I have different desire levels — is this fixable?

Desire discrepancy is one of the most common sexual concerns in couples. Sex therapy substantially improves outcomes through addressing each partner's desire patterns, communication, expectations, sensual reintegration, and treatment of any underlying contributors. Most couples experience meaningful improvement.

Is asexuality a mental-health concern?

No. Asexuality (lack of sexual attraction to others) is recognized as a sexual orientation, not a disorder. The DSM-5-TR explicitly excludes asexuality from sexual dysfunction diagnoses. Asexual individuals may seek therapy for related concerns (identity exploration, relationship navigation, processing partner reactions) but asexuality itself is not pathologized.

How long does sex therapy take?

Brief focused work for specific concerns may run 8-15 sessions. More complex or relational concerns may extend to 6-12 months. Trauma-related sexual concerns often require longer-term work integrated with trauma processing. Many people benefit from periodic check-ins after acute treatment.

References

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). APA.
Brotto, L. A. (2018). Better Sex Through Mindfulness: How Women Can Cultivate Desire. Greystone.
Wincze, J. P., & Weisberg, R. B. (2015). Sexual Dysfunction: A Guide for Assessment and Treatment (3rd ed.). Guilford Press.
Nagoski, E. (2015). Come As You Are: The Surprising New Science That Will Transform Your Sex Life. Simon & Schuster.
American Association of Sexuality Educators, Counselors and Therapists (AASECT). (n.d.). Resources and clinician directory.

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ShiftGrit Psychology & Counselling is professionally regulated, certified, and recognized by leading psychology and mental-health organizations across Alberta and Canada. These associations reflect our commitment to ethical practice, clinical standards, and evidence-informed therapy through Identity-Level Therapy and Reconditioning.

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The ShiftGrit Clinical Editorial Team combines the insight of registered psychologists, provisional psychologists, and trained writers to create accessible, evidence-informed therapy resources. All content is clinically reviewed by a Registered Psychologist.