ORIGINAL RESEARCH & REVIEWS

BEHAVIOR

Talking About Sexuality With Youth: A Taboo in Psychiatry?

Sara L. Bungener, MD, PhD, Laura Post, MD, Inez Berends, Msc, Thomas D. Steensma, PhD,
Annelou L.C. de Vries, MD, PhD, and Arne Popma, MD, PhD

Downloaded from https://academic.oup.com/jsm/article/19/3/421/6961215 by Universidade Católica Portuguesa user on 27 October 2023

ABSTRACT

Background: Young people who have psychiatric problems are more likely than their peers to endure difficulties
during their sexual and gender identity development.
Aim: This study aims to examine the communication between mental health care providers and their patients
about the topics of relations, sexuality and gender identity, including a description of professionals’ attitudes
toward these topics and the factors that contribute to and inhibit communication.
Methods: Study participants (n = 242, response rate = 31%) were a representative sample of a large multicenter
cohort of 768 mental health care professionals (eg, medical doctors, psychiatrists, psychologists, group counselors,
parent counselors) of 7 institutions and 5 solo practices in the Netherlands, who completed a survey on commu-
nication about sexuality and gender identity with their young patients (age 12−21 years).
Outcomes: Sexuality and gender identity are infrequently discussed by mental health care providers with their
young patients or their patients’ parents.
Results: Of the study sample, 99.5 % valued sexuality as an important topic to discuss with their patients. How-
ever, only 17.1% of the professionals reported that they discussed sexuality-related issues with the majority (>75%)
of their patients (adolescents: 19.9%, parents: 14.4%) Additionally, only 2.3 % of the participants discussed gender
nonconformity regularly with patients. Information about sexual side effects of prescribed medication was infre-
quently (20.3%) provided: antidepressants (40.0%), antipsychotics (34.0%), benzodiazepines (5.1%) and stimu-
lants (2.4%). The most frequently cited reasons for not discussing these topics were a lack of awareness, own
feelings of discomfort, and the patients’ supposed feelings of shame. There was no gender differences observed.
Clinical implications: Recommendations for professionals include to be aware of these topics, initiating age-
appropriate conversation and use inclusive language.
Strengths and limitations: The present study included a diverse and representative group of mental health care
professionals. Frequency of sexual communication was based on self-report, which brings a risk of bias.
Conclusion: Despite a recognized need to engage in age-appropriate communication about sexuality and gender
identity in youth mental health care, mental health providers seem to remain hesitant to discuss such topics. Bun-
gener SL, Post L, Berends I, et al. Talking About Sexuality With Youth: A Taboo in Psychiatry? J Sex Med
2022;19:421−429.
Copyright © 2022 The Authors. Published by Elsevier Inc. on behalf of the International Society for Sexual
Medicine. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
KEY WORDS: Child- and Adolescent Psychiatry; Sexuality; Gender Identity; Sexual Health

INTRODUCTION
Mental health counseling of youth involves discussion and
evaluation of a variety of topics, including psychological func-
Received April 21, 2021. Accepted January 1, 2022.
tioning, social functioning and family functioning. Private topics
Center of Expertise on Gender Dysphoria, Department of Child and Adoles-
cent Psychiatry, Department of Medical Psychology, Amsterdam University
such as sexuality and gender identity, though equally important,
Medical Centers, Amsterdam, the Netherlands may be discussed infrequently. This study aims to examine the
Copyright © 2022 The Authors. Published by Elsevier Inc. on behalf of the frequency of discussion of these private themes during consulta-
International Society for Sexual Medicine. This is an open access article
under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
tion with mental health care providers, as well as contributing
https://doi.org/10.1016/j.jsxm.2022.01.001 and inhibiting factors.

J Sex Med 2022;19:421−429 421

422 Bungener et al

Sexuality encompasses sexual behavior, gender identities and nonminority adolescent peers to suffer emotional and physical
roles, sexual orientation, pleasure, intimacy and reproduction.1 health concerns, and the suicide risk among adolescents in sexual
Sexual development begins in early childhood and accelerates minority groups is 4.5 till 10 times higher than that of their
during puberty due to the release of hormones. Sexual and rela- peers.27,28,29,30
tional experiences are generally obtained in an age dependent Given these challenges during the developmental phase of
and progressive line of intimacy: at the start of puberty, most adolescence, youth with mental health disorders should have
adolescents have not yet kissed, while at the end the majority opportunities to converse about these challenges and seek help if
have some sexual experience with others.2,3 necessary.31 A consultation with a mental health provider could

Downloaded from https://academic.oup.com/jsm/article/19/3/421/6961215 by Universidade Católica Portuguesa user on 27 October 2023

The path of sexual development can be challenging for adoles- be a designated setting to safely discuss these themes. In a sub-
cents in general. However, it may be more challenging for those question of a broader study on sexual dysfunctions among young
adolescents who have a psychiatric disorder because factors associ- patients with mental health disorders, 87.4% believed that men-
ated with the disorder (eg, low self-esteem, enduring mental tal health care providers should include sexual health care sup-
health-related stigma and social exclusion) may interfere with the port as part of their services.25 However, besides this item no
ability to form relationships and obtain sexual experiences.4,5,6,7,8 data currently exist regarding (age-appropriate) communication
Problems related to sexuality can have a profound impact on qual- about sexuality and gender diversity between mental health care
ity of life in general.9,10,11,12 The available literature on sexuality professionals and youth with a psychiatric condition
among youth with psychiatric conditions is primarily focused on Research in adult psychiatry has found that communication
negative and risky behaviors rather than healthy sexual develop- regarding sexual topics is scarce: only 24% of psychiatry residents
ment. Difficulties in relationship formation and sexual behavior (medical doctors specializing in psychiatry) reported that they
(such as deviant behavior) have been reported among children and asked patients about sexual problems, and 30% reported that
adolescents with Autism Spectrum Disorders (ASD).13,14 Rela- they asked patients about sexual side effects when prescribing
tively high incidence of risky sexual behavior, sexually transmitted medication.32 The majority of psychiatry residents (69%) felt
disease and teenage pregnancy have been observed among uncomfortable discussing sexual issues with patients.33
adolescents with attention deficit hyperactivity disorders
(ADHD).15,16,17 Sexual abuse during childhood and adolescence Sexuality can be a challenging topic for youth with psychiatric
is highly prevalent worldwide.18 Young people attending mental disorders, and communication about sexuality with mental
health clinics are at risk of having been exposed to sexual abuse, health care providers could be a taboo
which is associated with the development of psychiatric The present study aims to answer the following questions:
disorders.19,20 Structured assessment of trauma has been recom- How frequently do mental health care providers (including psy-
mended during mental health screening 20 chologists, psychiatrists/residents, group counselors and parent’s
Adolescents who struggle with personality disorder and counselors) communicate with their young patients and their
trauma are more likely than their peers to engage in sexual risk patients’ parents about sexuality and gender identity? What are
behavior, teenage pregnancy, sexual harassment and re- mental health care providers’ opinions and attitudes toward
traumatization.21,22 Young people who have anxiety disorders this subject? What factors contribute to communication about
report more sexual dysfunction and relationship dissatisfaction sexuality?
than their peers.23,24 In an Australian study of a clinical adoles-
cent psychiatric population, 95.8% of the young persons
reported that they had experienced at least 1 symptom related to METHODS
sexual dysfunction.25 Additionally gender identity and gender
Participants
nonconformity (see Box 1) are increasingly recognized as impor-
Data were collected from May 2017 to September 2017
tant elements of youth development. In recent years, the number
through an online survey, which was sent to a cohort of 786
of youth who struggle with their gender identity and seek help
mental health care professionals working in child and adolescent
related to this issue has increased.26 Adolescents who are in sex-
psychiatry in the Netherlands. To obtain a representative sample
ual diversity groups (LGBTIQ: lesbian, gay, bisexual, transgen-
of health care professionals, 7 youth mental health institutions
der, intersex, queer/questioning) are more likely than their
(academic and non-academic) and 5 solo practices were con-
tacted by email for recruitment. The range of participant profes-
Box 1 Explanatory Words sions included: medical doctors (n = 42, psychiatrists and
Gender identity: a person's own experienced gender, which can cor- residents) psychologists (n = 115, basic psychologists, healthcare
relate or differ from a persons assigned sex at birth. Gender non con- psychologists, clinical psychologists, psychotherapists, creative
formity: a person who does not conform with the gender norms that therapists and education generalists) group counselors (n = 50,
are expected. Gender inclusive language: speaking and writing in a
sociotherapists and psychiatric nurses at inpatient clinics) and
way that does not discriminate against a particular sex, social gender
or gender identity, and does not perpetuate gender stereotypes.
parent counselors (n = 26, system therapists and social workers).
Respondents worked in a range of settings, including inpatient

J Sex Med 2022;19:421−429

Talking About Sexuality in Youth Psychiatry 423

Table 1. General characteristics of mental health care professio- is between 0 and 21 years, for this survey the aim was on youth
nals and treated patients 12−21 years.
All participants Respondents were invited to participate in an online survey
Variabele N = 242 (%) through a variety of methods, including targeted mailings, and per-
Age at assesment sonal invitations. Three reminder notifications were sent out after
M(SD) 40.01 (11.31) the initial invitation, and a gift certificate was raffled among the par-
Range 23.00 - 65.00 ticipants as an incentive to complete the survey. For privacy reasons,

Downloaded from https://academic.oup.com/jsm/article/19/3/421/6961215 by Universidade Católica Portuguesa user on 27 October 2023

Gender, N (%) the survey was fully digital and could be completed on a self-chosen
Female 201 (83) moment and device. Of the 786 invited professionals, 262 partici-
Male 41 (17) pated in the survey. Incomplete survey data were collected for 20
Profession, N (%) participants, because the survey system required participants to com-
Medical Doctors 42 (17.4) plete the survey within a single log-in session. Therefore, complete
Psychiatrists 16 (6.7) survey data were collected for 242 participants, resulting in a 31%
Residents 26 (10.7) response rate. Participants gave formal consent for anonymous proc-
Psychologists 115 (47.5) essing of data. All survey data were de-identified and processed by
Psychologist (healthcare/basic/clinical) 75 (31.0) an independent data scientist before analysis by our researchers.
Psychotherapists 17 (7.0) Representability could be calculated for 70% of the sample, this
Creative therapists 15 (6.2) group was found to be representative of Dutch mental health care
Education genera lists 12 (5.0)
providers by gender, age and profession. For 30% of the sample,
Groupcounselors 50 (20.7)
the demographic data of the non-responders could not be retrieved
Parent counselors 26 (10.7)
to calculate sample representability.
systemic therapists 13 (5.3)
social workers 13 (5.3)
Work setting, N (%)a
Clinic 69 (28.5) Measures
Outpatient clinic 184 (76.0) Data were collected regarding participant demographics (gen-
Dayclinic 29 (12.0) der, age, profession and current type of clinic). General informa-
Solo practice 15 (6.2) tion about the study participants’ patients was collected through
Age of patientsa,b responses to multiple-choice questions (age group of patients and
12−18 years 198 (81.8) most common psychiatric disorders of the patient group, see
18−21 years 53 (21.9) Table 1)
Diagnosis of patientsa,b,c To assess participants’ communication about sexuality, a
ADHD 134 (59.1)
questionnaire was designed and developed by a panel of experts
ASD 126 (52.1)
from 2 institutions. The panel included child and adolescent psy-
Anxiety/OCD 107 (44.2)
chiatrists, a resident, a psychologist, a sexologist and a survey data
Trauma 102 (42.1)
expert. During the development process, the questionnaire was
Personality disorder 92 (38.0)
pilot tested with a group of mental health care professionals in
Mood disorder 87 (36.0)
Intellectual dissability 47 (19.4)
different clinical settings to test for ease of use and applicability.
Eating disorder 43 (17.8) Three of the questions were derived from the questionnaire used
Somatic Symptomen disorder 34 (14.0) by Voermans et al. for medical doctors and residents in adult psy-
Genderdysphoria 21 (8.7) chiatry.32 At the start of the survey, the term “sexuality” was
Psychotic disorders 20 (8.3) defined to participants as “a broad term that covers all topics of
Addiction 20 (8.3) sexuality, such as: being in love, romantic relationships, (age-
Other 21 (8.7) appropriate) sexual behavior, sexual experiences, sexual orienta-
ADHD = attention deficit hyperactivity disorder; ASD = autism spectrum tion, risk behavior, trauma, and so on.” (See appendix 1)
disorder; OCD = obsessive compulsive disorder. Communication about sexuality was assessed for all mental
a
Multiple answer options.
b
General characteristics of patients treated by respondents.
health care professionals using 2 questionnaire items: the share of
c
Diagnosis according to the D SM-5 (Diagnostic and Statistical Manual of patients (adolescents or parents) with whom sexuality was dis-
Mental Disorders). cussed (6-point scale; 0−100%) and the treatment phase in
which this topic was discussed (multiple-choice responses).
clinics, day clinics, outpatient clinics, outreach clinics and solo Other questionnaire items asked the participants opinions about
practice (See Table 1 for a demographic description of the study the importance of discussing sexuality with adolescent patients,
participants). The age range of the young people who are treated who’s task it should be to discuss sexuality and what professionals
in these child and adolescent psychiatry institutions and practices thought about their own attention to this topic (yes/no

J Sex Med 2022;19:421−429

424 Bungener et al

responses). Two questions with multiple choice options were conducted to compare the frequencies in communication
included regarding participants’ reasons not to discuss sexuality between the 4 groups of mental health care professionals: medical
and the specific topics they chose to discuss. All respondents doctors, psychologists, group counselors and parent counselors.
were asked whether they regarded their knowledge sufficient on A Bonferroni correction was applied for post-hoc analyses. Chi-
sexual development, referral options, treatment options and devi- square tests were also used to analyze differences in communica-
ant sexual development (yes/no responses). Questionnaire items tion among subgroups.
regarding gender identity included: the share of patients (adoles-
cents or parents) with whom the participant discussed the topic

Downloaded from https://academic.oup.com/jsm/article/19/3/421/6961215 by Universidade Católica Portuguesa user on 27 October 2023

of gender-nonconforming behavior and gender identity (6-point RESULTS
scale; 0−100%). Participants were also asked whether they had
sufficient knowledge regarding psychological problems among Communication About Sexuality Among Mental
youth related to gender-nonconforming behavior and problems Health Care Providers
with sexual orientation, and their knowledge about treatment Table 2 presents the frequency of communication about sexu-
and referral options (yes/no responses). ality-related topics among the total sample of health care pro-
viders and for each of the different professional groups.
Among professionals who prescribed medication (residents and
Significant differences were observed between the different
child/adolescent psychiatrists), communication about sexual side
groups of professionals regarding their communication with ado-
effects was assessed using items regarding participants’ knowledge
lescents (F(3, 212) = 9.18, P = .00) and parents (F(3,
about sexual side effects (yes/no response) and the frequency with
225) = 20.38, P = .00). Post-hoc analysis indicated that group
which participants provided information about sexual side effects
counselors discussed sexuality significantly less often with adoles-
to their patients (including for antidepressant medications, stimu-
cents than did medical doctors (-1.08 § 0.27, P = .00) or psy-
lant medications, antipsychotics and benzodiazepines). Additional
chologists (-1.12 § 0.22, P = .00). Parent counselors talked
items included participants’ observed frequency of sexual side
more often with parents about sexuality than all other professio-
effects and likelihood to provide a patient referral in case of side
nals.
effects (4-point scale; “almost always” to “never”).
Just 17.1% of mental health care providers reported that they
discussed sexuality with at least 75% of their patients. Specifically,
Analyses 19.9% of providers reported discussing this topic with most of
Descriptive statistics and an independent t-test were used to their adolescent patients, 14.0% with most of their patients’
describe participant demographic data. A one-way ANOVA was parents. Professional group differences in communication about

Table 2. Communication about sexuality with young patients and parents by mental health care providers
Medical doctorse Psychologistsf Groupcounselorsg Parent counselorsh All health care providersb
Patientgroupa N= 42 N (%) N = 115 N (%) N = 56 N (%) N = 29 N (%) N = 242 N (%)
Adolescentsc
0% 0 (0.0) 1 (0.9) 3 (6.8) 0 (0.0) 4 (1.9)
1−5% 0 (0.0) 9 (8.3) 5 (11.4) 2 (8.7) 16 (7.4)
6−25% 9 (22.0) 20 (18.5) 15 (34.1) 4 (17.4) 48 (22.2)
26−50% 10 (24.4) 18 (16.7) 15 (34.1) 4 (17.4) 53 (24.5)
51−75 % 17 (41.5) 27 (25.5) 4 (9.1) 4 (17.4) 52 (24.1)
> 75 % 5 (12.2) 33 (30.6) 1 (2.3) 4 (17.4) 43 (19.9)
Parentsd
0% 1 (2.4) 5 (4.7) 11 (21.6) 0 (0.0) 17 (7.4)
1−5% 13 (31.0) 21 (19.6) 15 (29.4) 0 (0.0) 49 (21.4)
6−25% 15 (35.7) 24 (22.4) 19 (37.3) 8 (27.6) 66 (28.8)
26−50% 8 (19.0) 24 (22.4) 3 (5.9) 5 (17.2) 40 (17.5)
51−75 % 4 (9.5) 15 (14.0) 2 (3.9) 4 (13.8) 25 (10.9)
> 75 % 1 (2.4) 18 (16.8) 1 (2.0) 12 (41.4) 32 (14.0)
a
% of patients or parents where sexuality is discussed by the respondent.
b
For description see below.
c
Adolescents > 12-21 years.
d
Parents of young patients in mental health care.
e
Medical doctors: child- and adolescents psychiatrists, residents (MD, medical doctor, either specializing/non specializing).
f
Psychologists: psychologists of all levels, psychotherapists, education generalists, creative therapists.
g
Group counselors: sociotherapists, psychiatric nurses.
h
Parent counsellors: system therapists, social workers.

J Sex Med 2022;19:421−429

Talking About Sexuality in Youth Psychiatry 425

sexuality were observed, in that psychologists communicated Table 3. Communication about gender non-conform behavior and
about this topic more often (30.6%) than medical doctors gender identity
(12.2%; x2(1) = 4.72, P < .05). Group counselors communicated Gender non conformb Gender identityc
a
about sexuality significantly less than participants in all other pro- Frequencies N (%) N (%)
fessions (2.3%; x2(1) = 9.17, P < .05). No gender differences
0% Never 49 (21.4) 59 (25.8)
were observed between male and female professionals in terms of
1−5% 68 (29.7) 96 (41.9)
frequency of discussing sexuality-related topics (adolescents: 6−25% 65 (28.4) 47 (20.5)
x2(1) = 1.78, P = .18; parents: x2(1) = 3.06, P = .080).

Downloaded from https://academic.oup.com/jsm/article/19/3/421/6961215 by Universidade Católica Portuguesa user on 27 October 2023

26−50 24 (10.5) 12 (5.2)
The vast majority of participants in all professional groups 51−75 9 (3.9) 8 (3.5)
(99.5%) reported that communication about sexuality with ado- 76−100 6 (2.6) 0 (0.0)
lescents was important. The majority of participants (93.7%) a
% of patients or parents where gender topics are discussed by mental
considered the task of communicating about sexuality to be part health care professionals.
b
Gender non conform behavior: behavior doens’t match the gender norms
of their profession, and most participants (94.6%) reported that
that are expected.
they did not pay enough attention to this subject. No differences c
Gender identity: a person's own experienced gender, which can correlate or
were observed between professional groups regarding these differ from a persons assigned sex at birth.
items.
The most common reasons participants reported that they did Communication About Gender Identity and Gender
not discuss sexuality with patients included “not thinking about Nonconformity
it” (33.1%), “the patient will be ashamed” (31.4%), “the patient The findings presented in Table 3 indicate that mental health
cannot handle a conversation about sexuality” (25.6%), lacking care providers (who do not work at transgender clinics) do not
time (22.7%) and the health care provider’s feelings of shame frequently talk about gender-nonconforming behavior or gender
(20.2%). In case sexuality was discussed, the topics that were identity. In the transgender clinic, all mental health care pro-
most frequently addressed included: being in love (86.0%), rela- viders talked about these themes frequently. In the study sample,
tionships (80.2%), sexual trauma (67.8%), sexual experiences 21.4% of mental health care professionals had never spoken with
(65.7%), sexual risk behavior (56.6%), sexual orientation their patients about gender-nonconforming behavior, and
(52.1%), deviant sexual behavior (21.1%), sexual harassment 25.8% had never discussed gender identity issues with their
(50.5%), sexual development phases (35.5%), sex and social patients. Additionally, the professionals in the sample stated that
media (33.9%), gender diversity (29.9%) and sexual dysfunc- they had some knowledge of gender identity development
tions (2.5%). No differences in responses were observed between (58.6%), psychological problems that co-exist with gender-non-
male and female mental health care professionals. conforming behavior (29.5%) and referral options for these
Conversations about sexuality-related topics were often initi- issues (12.3%).
ated by the health care provider (54.3%). These conversations
were sometimes initiated both professional and patient (29.1%)
and occasionally by the patient or parent (12.9%). If sexuality
DISCUSSION
was assessed, these conversations most often took place in fol- This study examined communication about sexuality and
low-up treatment (84.7%), at intake (45.0%) or in clinical group gender identity between mental health care professionals, their
counseling (10.3%). The majority of survey respondents had no adolescent patients and the parents of those patients. The find-
experience providing treatment or counseling for sexual problems ings illustrate that practically all mental health care professionals
(75.1%) or providing a referral to a specialist for sexuality-related think sexuality and gender identity should be addressed but seem
topics (77.1%). to be hesitant to discuss these topics with their patients. The
main reasons mental health care professionals indicated not to
address sexuality with their patients were lack of awareness, pre-
MEDICATION sumed feelings of shame experienced by the patient, lack of time
A large majority (72%) of the medical doctors (residents and the professional’s own feelings of shame. The majority of
and psychiatrists) in the study sample rated their knowledge participants reported that they did not communicate with their
level of sexual side effects as sufficient. However, 20.3% of patients about gender identity or gender nonconformity.
the doctors reported that they provided >75% of their Almost all (99.5%) of the professionals in our study stated
patients with information about sexual side effects when pre- that sexuality is an important topic to discuss with young
scribing medications; antidepressants (40.0%), antipsychotics patients and an almost as large group of professionals (93.7 %)
(34.0%), benzodiazepines (5.1%) and stimulants (2.4%). No indicated that they considered it to be part of their professional
gender differences or differences between residents and psy- duty. This finding echoes the arguments of various researchers
chiatrists were observed. who have emphasized the importance of including sexuality in

J Sex Med 2022;19:421−429

426 Bungener et al

youth mental health care.10,31,34 One even stated: Not asking increasing. In the USA 1.8% transgender and 1.6% is question-
about these (sexual) experiences can be compared with not mea- ing. This can remain undisclosed for a long period and psycho-
suring head circumference of infants during the first year of logical problems, including suicidality frequently occur
life.31 We are not convinced that sexuality should be discussed associated with these struggles.26,27,28,41Therefore, MHP work-
with all young people at all times. There are situations such as an ing with adolescents could create a safe environment to enable
acute psychiatric situation (eg, severe manic episode or psycho- young persons to talk about their (gender) identity.26,27,28
sis), where it is less relevant. However, given that young people Why is it so difficult to communicate about these topics with
receiving mental health care during the developmental phase in

Downloaded from https://academic.oup.com/jsm/article/19/3/421/6961215 by Universidade Católica Portuguesa user on 27 October 2023

youth receiving mental health care? In order to understand the
which sexuality and relationships play a major role some form of underlying reasons for not discussing it, we looked at comparable
attention for these subjects is recommended. literature from adjacent fields, that of adult psychiatry and that of
Furthermore, the fact they are more vulnerable (due to a general (not mental/psychiatric) youth health care. In our study,
higher chance of trauma in history18,19,20, sexual side effects of a lack of awareness about this topic was most frequently given as
medication31, and other reasons), it would be desirable if profes- reason why providers did not talk about sexuality with their
sionals create opportunities during treatment to engage in con- patients. This is in line with literature describing a lack of knowl-
versations about these topics with youth to support healthy edge and practice among health care professionals.32,33,42,43,44,45
sexual development. Recently, some medical, psychology and psychiatry universities
In the present study, youth mental health care providers started with the implementation of sexual education and com-
reported discussing sexuality frequently (stated as: with at least munication skills in the standard curriculum.46,47,48
75% of their patients) with 17.1% of their patients (19.9% of The second most frequently cited reason in this study was
adolescents, 14.4% of parents The incidence of sexuality-related concern about the patient’s supposed feelings of shame or dis-
discussion is lower than that reported in adult psychiatry studies. comfort. Avoiding discussion about sexuality to protect the
Voermans et al. reported that 43% of residents and psychiatrists patient from supposed discomfort has been described before in
regularly addressed sexuality with their adult patients, and Rele the literature.45 Research in general (nonmental) health care
reported that 24% of psychiatric trainees routinely asked adult among young patients has found that some adolescent patients
patients about their psychosexual history.32,33 These findings do report discomfort with this topic: 99% of patients said it was
indicate that it is already difficult to address sexuality in adult easy to talk to their doctor in general, but 57% said it was
psychiatry, however, communication with young patients about uncomfortable to address a sexual problem with their doctor.
this topic may pose additional challenges for youth mental health Feelings of discomfort are most likely to occur when there is no
care professionals. understanding of the purpose of discussion, when young patients
Few of the medical doctors (residents and psychiatrists) in this are feeling judged or when the patients do not trust that the con-
study reported that they frequently (> 75% of their patients) versation is private.49 For LHBTIQ youth a lack of inclusive lan-
informed their young patients about sexual side effects when pre- guage during healthcare visits may lead to feel a lack of
acceptance.42 A study of audio recordings of patients visiting
scribing psychotropic medications (20.3 %). This is less frequent
their general practitioner has indicated that inclusive language
than the conversations reported by medical professionals in adult
(see Box 1) was rarely observed (3.3%), and noninclusive lan-
psychiatry (antidepressants; 66.7% and antipsychotics; 40.0%). guage was predominant (48.%).42
32
The few studies on sexual side effects on youth receiving psy-
It is possible that the supposed shame of the patient is in fact
chotropic medication mirror the high prevalence of sexual dys-
the shame or discomfort experienced by the professional. In adult
function found among adult samples.10,11,25,35,36
psychiatry, 50−69% of psychiatrists and residents reported feel-
Sexual dysfunction also occurs in people who have mental ings of shame around sexuality.32,33 In the current study, 20.2 %
health disorders and do not take medication; however, sexual
of the participants experienced shame or discomfort. Qualitative
dysfunction can negatively affect medication adherence for those
who do take medication.37,38,39,40 Therefore, communication research in youth general health care settings has found that it is
about the sexual side effects of medication is essential to increase easier for young patients to discuss gender identity and sexuality-
patient adherence to psychotropic medication treatment and related topics if their health care provider is indeed comfortable
should be initiated as part of standard protocol by medical with such topics.28, 50
doctors.10,31,32,29 Lack of time has also been reported as a reason not to include
Gender identity and gender nonconformity were rarely the topic of sexuality during health care visits. In conversations
addressed among the present study sample: 25.8% of the mental between general practitioners (GP) and young patients, conversa-
health care professionals had never spoken with their patients tions of a longer duration were more likely to include sexuality
about these subjects. Adolescence is pre-eminently a period of topics than shorter conversations.50,51 This is an interesting
identity formation, including gender identity. The number of result, since in general, conversations in psychiatric care tend to
young people who are struggling with their gender identity is be longer than those in GP visits. Moreover, previous studies in

J Sex Med 2022;19:421−429

Talking About Sexuality in Youth Psychiatry 427

adult psychiatry did not find a relationship between lack of time 6. Longmore M, Manning W, Giordano P, et al. Self-esteem,
and exclusion of sexuality topics.32,33 depressive symptoms, and adolescents’ sexual onset. Soc
Psychol Q 2004;67:279–295.
The present study has some limitations. Respondents were
asked to estimate their frequency of sexual communication, 7. Hortal-Mas R, Moreno-Poyato AR, Granel-Gimenez N, et al.
which brings a risk of bias and may have provoked socially desir- Sexuality in people living with a serious mental illness: A
meta-synthesis of qualitative evidence [published online ahead
able answers. If this is the case, the percentage of respondents
of print, 2020 Oct 12]. J Psychiatr Ment Health Nurs 2020.
who communicate about sexuality on a regular basis could be
8. Wright ER, Wright DE, Perry BL. Foote-Ardah CE. Stigma and

Downloaded from https://academic.oup.com/jsm/article/19/3/421/6961215 by Universidade Católica Portuguesa user on 27 October 2023

lower than reported.
the sexual isolation of people with serious mental illness. Soc
In the future, qualitative studies could address clinician and Probl 2007;54:78–98.
patient perspectives in greater detail to understand the barriers 9. Rosen RC, Seidman SN, Menza MA, et al. Quality of life,
and facilitators of communication about sexuality in mental mood, and sexual function: A path analytic model of treatment
health care. effects in men with erectile dysfunction and depressive symp-
In conclusion, almost all mental health care providers find it toms. Int J Impot Res 2004;16:334–340.
important and their task to communicate about sexuality and 10. Scharko AM. Selective serotonin reuptake inhibitor-induced
gender identity with adolescent patients. However, in practice sexual dysfunction in adolescents: A review. J Am Acad Child
they seem to avoid these topics, due to a lack of awareness, time, Adolesc Psychiatry 2004;43:1071–1079.
presumed feelings of shame of the patient and professional’s 11. Williams VS, Edin HM, Hogue SL, et al. Prevalence and impact
shame. It would be advisable for professionals to initiate and of antidepressant-associated sexual dysfunction in three
enable age-appropriate conversations about these topics, espe- European countries: Replication in a cross-sectional patient
cially when prescribing psychotropic medications or screening survey. J Psychopharmacol 2010;24:489–496.
for sexual trauma.52 12. Rosen RC, Seidman SN, Menza MA, et al. Quality of life,
mood, and sexual function: A path analytic model of treatment
effects in men with erectile dysfunction and depressive symp-
Corresponding Author: Sara L. Bungener, MD, PhD, Amster- toms. Int J Impot Res 2004;16:334–340.
dam UMC, VUmc, Amsterdam, Noord-Holland, Netherlands. 13. Dewinter J, Vermeiren R, Vanwesenbeeck I, et al. Autism and
Tel: +0642989828; E-mail: [email protected] normative sexual development: A narrative review. J Clin
Nurs 2013;22:3467–3483.
Conflict of Interest: The authors report no conflicts of interest.
14. Gougeon NA. Sexuality and autism: A critical review of
Funding: None. selected literature using a social relational model of disability.
Am J Sex Educ 2010;5:328–361.
STATEMENT OF AUTHORSHIP 15. Hechtman L, Swanson JM, Sibley MH, et al. Functional adult
S.L.B, L.P. and A.P. conceptualised the study, S.L.B and L.P. outcomes 16 years after childhood diagnosis of attention-defi-
cit/hyperactivity disorder: MTA results. J Am Acad Child
performed the survey, I.B. curated the data, S.L.B analysed the
Adolesc Psychiatry 2016;55:945–952.e2.
data and wrote the manuscript, L.P., I.B., A.P., A.L.C.d.V and
T.D provided expertise and feedback. 16. Hosain GM, Berenson AB, Tennen H, et al. Attention deficit
hyperactivity symptoms and risky sexual behavior in young
adult women. J Womens Health (Larchmt) 2012;21:463–468.
REFERENCES 17. Marsh LE, Norvilitis JM, Ingersoll TS, et al. ADHD symptom-
1. World Health Organization, WHO, 2006a, Updated 2010. atology, fear of intimacy, and sexual anxiety and behavior
2. Baams L, Dubas JS, Overbeek G, et al. Transitions in body and among college students in China and the United States. J
behavior: A meta-analytic study on the relationship between Atten Disord 2015;19:211–221.
pubertal development and adolescent sexual behavior. J Ado- 18. Responding to children and adolescents who have been sexu-
lesc Health 2015;56:586–598. ally abused, WHO clinical guidelines, 2017, ISBN: 978-92-4-
3. de Graaf H, Vanwesenbeeck I, Meijer S, et al. Sexual trajecto- 155014
ries during adolescence: Relation to demographic characteris- 19. Skar AS, Ormhaug SM, Jensen TK. Reported levels of upset in
tics and sexual risk. Arch Sex Behav 2009;38:276–282. youth after routine trauma screening at mental health clinics.
4. Silverstone PH, Salsali M. Low self-esteem and psychiatric JAMA Netw Open 2019;2:e194003.
patients: Part I - The relationship between low self-esteem 20. Rossiter A, Byrne F, Wota AP, et al. Childhood trauma levels in
and psychiatric diagnosis. Ann Gen Hosp Psychiatry individuals attending adult mental health services: An evalua-
2003;2:2. tion of clinical records and structured measurement of child-
5. Boin AC, Nozoe KT, Polesel DN, et al. The potential role of hood trauma. Child Abuse Negl 2015;44:36–45.
sleep in sexual dysfunction in patients with schizophrenia. 21. Hamerlynck SM, Cohen-Kettenis PT, Vermeiren R, et al. Sex-
Schizophr Res 2014;154:126–127. ual risk behavior and pregnancy in detained adolescent

J Sex Med 2022;19:421−429

428 Bungener et al

females: A study in Dutch detention centers. Child Adolesc 36. Knegtering H, van der Moolen AE, Castelein S, et al. What are
Psychiatry Ment Health 2007;1:4. the effects of antipsychotics on sexual dysfunctions and endo-
22. Choukas-Bradley S, Hipwell AE, Roberts SR, et al. Develop- crine functioning? Psychoneuroendocrinology 2003;28
mental trajectories of adolescent girls’ borderline personality (Suppl 2):109–123.
symptoms and sexual risk behaviors. J Abnorm Child Psy- 37. Kennedy SH, Dickens SE, Eisfeld BS, et al. Sexual dysfunction
chol 2020;48:1649–1658. before antidepressant therapy in major depression. J Affect Dis-
23. Hebert KR, Fales J, Nangle DW, et al. Linking social anxiety ord 1999;56:201–208.
and adolescent romantic relationship functioning: Indirect 38. Marques TR, Smith S, Bonaccorso S, et al. Sexual dysfunction

Downloaded from https://academic.oup.com/jsm/article/19/3/421/6961215 by Universidade Católica Portuguesa user on 27 October 2023

effects and the importance of peers. J Youth Adolesc in people with prodromal or first-episode psychosis. Br J Psy-
2013;42:1708–1720. chiatry 2012;201:131–136.
24. Montesi JL, Conner BT, Gordon EA, et al. On the relationship 39. de Boer MK, Castelein S, Wiersma D, et al. The facts about
among social anxiety, intimacy, sexual communication, and sexual (Dys)function in schizophrenia: An overview of clinically
sexual satisfaction in young couples. Arch Sex Behav relevant findings. Schizophr Bull 2015;41:674–686.
2013;42:81–91.
40. Serretti A, Chiesa A. A meta-analysis of sexual dysfunction in
25. McMillan E, Adan Sanchez A, Bhaduri A, et al. Sexual function- psychiatric patients taking antipsychotics. Int Clin Psycho-
ing and experiences in young people affected by mental health pharmacol 2011;26:130–140.
disorders. Psychiatry Res 2017;253:249–255.
41. de Lange J, van Bergen DD, Baams L. Experiences and needs
26. Aitken M, Steensma TD, Blanchard R, et al. Evidence for an of sexual and gender minority young adults with a history of
altered sex ratio in clinic-referred adolescents with gender suicidal ideation regarding formal and informal mental health-
dysphoria. J Sex Med 2015;12:756–763. care. Sex Res Soc Policy 2021.
27. Collier KL, van Beusekom G, Bos HM, et al. Sexual orientation 42. Alexander SC, Fortenberry JD, Pollak KI, et al. Physicians use
and gender identity/expression related peer victimization in of inclusive sexual orientation language during teenage annual
adolescence: A systematic review of associated psychosocial visits. LGBT Health 2014;1:283–291.
and health outcomes. J Sex Res 2013;50:299–317.
43. Stevenson RW. Sexual medicine: Why psychiatrists must talk
28. Fuzzell L, Fedesco HN, Alexander SC. "I just think that doctors to their patients about sex. Can J Psychiatry 2004;49:673–
need to ask more questions": Sexual minority and majority 677.
adolescents' experiences talking about sexuality with health-
44. Nnaji R, Friedman T. Sexual dysfunction and schizophrenia:
care providers. Patient Educ Couns 2016;99:1467–1472.
Psychiatrists' attitudes and training needs. Psychiatric Bulle-
29. J Adelson SL. American academy of child and adolescent psy- tin 2008;32:208–210.
chiatry (AACAP) committee on quality issues (CQI). Practice
45. Hughes E, Edmondson AJ, Onyekwe I, et al. Identifying and
parameter on gay, lesbian, or bisexual sexual orientation, gen-
addressing sexual health in serious mental illness: Views of
der nonconformity, and gender discordance in children and
mental health staff working in two National Health Service
adolescents. J Am Acad Child Adolesc Psychiatry
organizations in England. Int J Ment Health Nurs
2012;51:957–974.
2018;27:966–974.
30. Merelle S, Van Bergen D, Looijmans M, et al. A multi-method
46. Levine SB, Scott DL. Sexual education for psychiatric resi-
psychological autopsy study on youth suicides in the Nether-
dents. Acad Psychiatry 2010;34:349–352.
lands in 2017: Feasibility, main outcomes, and recommenda-
tions. PLoS One 2020;15:e0238031. 47. Miller SA, Byers ES. Psychologists’ sexual education and
training in graduate school. Can J Behav Sci /Rev Can Des sci
31. Levine A, McGlinchey E. Assessing sexual symptoms and side
Du Comportement 2010;42:93–100.
effects in adolescents. Pediatrics 2015;135:e815–e817.
48. Warner C, Carlson S, Crichlow R. Sexual health knowledge of
32. Voermans JM, Van HL, Peen J, et al. Het bespreken van sek-
U.S. medical students: A National Survey. J Sex Med
suele problemen door psychiaters en aiossen. Tijdschr Psy-
2018;15:1093–1102.
chiatr 2012;54:9–16.
49. Boekeloo BO, Schamus LA, Cheng TL. Young adolescents' com-
33. Rele K, Wylie K. Management of psychosexual and relation-
fort with discussion about sexual problems with their physician
ship problems in general mental health services by psychiatry
[published correction appears in Arch Pediatr Adolesc Med 1997
trainees. Int J Clin Pract 2007;61:1701–1704.
Feb;151(2):128]. Arch Pediatr Adolesc Med 1996;150:1146–1152.
34. Pfeffer B, Ellsworth TR, Gold MA. Interviewing adolescents
50. Alexander SC, Fortenberry JD, Pollak KI, et al. Sexuality talk
about sexual matters. Pediatr Clin North Am 2017;64:291–
during adolescent health maintenance visits. JAMA Pediatr
304.
2014;168:163–169.
35. McCabe MP, Sharlip ID, Lewis R, et al. Risk factors for sexual
51. Boekeloo BO. Will you ask? Will they tell you? Are you ready
dysfunction among women and men: A consensus statement
to hear and respond?: Barriers to physician-adolescent discus-
from the fourth international consultation on sexual medicine
sion about sexuality. JAMA Pediatr 2014;168:111–113.
2015. J Sex Med 2016;13:153–167.

J Sex Med 2022;19:421−429

Talking About Sexuality in Youth Psychiatry 429

52. Lahtinen HM, Laitila A, Korkman J, et al. Children's disclo- 1. With what percentage of young people do you discuss gender non-
sures of sexual abuse in a population-based sample. Child conforming behavior? (such as: do you prefer to play with boyish or
Abuse Negl 2018;76:84–94. girlish toys? Do you dress boyish or girlish? Do you prefer to play
with boys / girls?)
2. With what percentage of young people do you discuss gender iden-
tity? (like: Do you feel like a boy or a girl? Would you rather be of
APPENDIX 1. QUESTIONNAIRE the opposite gender?)
Communication about sexuality 3. Do you have sufficient knowledge of the normal gender identity

Downloaded from https://academic.oup.com/jsm/article/19/3/421/6961215 by Universidade Católica Portuguesa user on 27 October 2023

development of young people?
4. Do you have sufficient knowledge of the development and psycho-
1. With what percentage of young people (from 12 years and older)
logical problems of young people with gender non-conforming
do you discuss the topic of sexuality?
behavior?
2. Does the initiative for discussing the topic of sexuality lie more
5. Do you have sufficient knowledge of the specific development and
with you or with the child / young person?
psychological problems of young people with homosexual, bisexual
3. With what percentage of the parents / educators do you discuss or other sexual orientation?
the topic of sexuality?
6. Do you have sufficient knowledge of treatments for young people
4. Does the initiative for discussing the topic of sexuality lie more with gender non-conforming behavior?
with you or with the parents / educators?
7. Do you have sufficient knowledge of referral options?
5. At what stage of the treatment is the topic of sexuality discussed?
6. Do you think it is important that the topic of sexuality is discussed
with young people (12 years and older)? Communication about sexual side effects, treatment &
7. Is it part of your job to discuss the topic of sexuality? referrals
8. If not: which position does this belong to?
9. Do you think you pay enough attention to the topic of sexuality?
10. What are reasons for you to discuss the topic of sexuality? 1. Do you have sufficient knowledge of sexual side effects when using
medication?
11. What are reasons for not discussing the topic of sexuality?
2. Do you personally prescribe medication for young people?
12. When discussing sexuality, what topics are usually covered?
3. Do you explicitly provide information about sexual side effects
13. Do you have sufficient knowledge of the normal sexual develop-
when prescribing antidepressants?
ment of young people?
4. Do you explicitly provide information about sexual side effects
14. Do you have sufficient knowledge of the abnormal course of the
when prescribing antipsychotics?
sexual development of young people?
5. Do you explicitly provide information about sexual side effects
15. Do you have sufficient knowledge of treatments for problems with
when prescribing stimulants (such as methylphenidate)?
sexuality?
6. Do you explicitly provide information about sexual side effects
16. Do you have sufficient knowledge of referral options for problems
when prescribing benzodiazepines?
with sexuality?
7. Are there any other medications where you explicitly provide infor-
mation about sexual side effects? If so, specify drug:
Communication about Gender non-conformity and gender 8. How many times have you dealt with sexual problems?
identity 9. How many times have you referred someone?

J Sex Med 2022;19:421−429