What To Do When the Client Seems Cagey
There comes a point in every Sex OT evaluation when I ask, “What are y’all doing when you have sex? For example, how does it start, what happens next, and then what?”
If you work in any setting where you’re discussing sex or pelvic floor dysfunction, we need to know what sex looks like so we can do an activity analysis and identify where the breakdown is.
To these questions, clients usually say “huh,” give me a blank stare, or look visibly awkward and tense. These responses are common with many of the questions I might ask in a session. Given the topic, this can feel like a big “proceed with caution” sign—or even a “turn right the F around” sign.
However, what’s far more likely then the client doesn’t want to talk about it, is that the client doesn’t know how to talk about it.
Here are three vignettes that demonstrate how these conversations can go—and how you can give your client more permission and support them in a conversation they’ve likely never had.
State why you need to know:
When Sarah was asked what she and her husband do during sex, she gave a blank stare and said, “We kiss, and then, you know… and then some touching, and then you know.” To this, I responded, “Actually, I don’t know—I have no idea what happens after kissing. But it’s really helpful for me to understand what you’re physically doing so I can get a holistic picture of what’s going on.”
Give permission to use their own language:
My client Juan said to me, “I’m not sure what I’m allowed to say here.” This made me think about all the clients who might be holding back but don’t say it out loud. I had another client, Steve, who at the end of our first session said, “Um, I’m finding it kind of weird to use words like ‘vagina’ and ‘vulva.’ Is it okay if next session I use the word ‘pussy’?” To this, I of course said, “Yes.” After that, I started explicitly giving clients permission to use their own words. I realized how much effort clients put into not offending me—and I’d much rather they use that energy to speak freely and share what’s necessary for their treatment. Oftentimes I smile and say, “I’ll let you know if I’m offended—but I haven’t been yet, and I don’t think today will be the day.”
Normalize the awkwardness:
With almost everyone I work with, I think it’s worth noting that sex is inherently awkward to talk about—and we don’t need to fake some funk that it’s not. I usually say something like, “It’s okay, I know this is awkward. Sex can be awkward to talk about, but we’ll get through it together,” or “Hey, this is tough to talk about—it’s not easy, and it can feel really awkward. That’s to be expected, and we can take our time or even make some silly jokes.”
If you have a strong clinical sense that a client isn’t comfortable, you can always say, “If there’s a question I ask that you don’t want to answer, just let me know and we’ll move on.” I actually say this at the beginning of every evaluation so clients understand their agency and know they can guide the conversation.
Want more? Check out ISOT’s continuing education courses with the coolest community of OTs to help you build your confidence and competence in addressing sex with your patients. Get certified!
