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

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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

Received April 21, 2021. Accepted January 1, 2022.
Center of Expertise on Gender Dysphoria, Department of Child and Adoles-
cent Psychiatry, Department of Medical Psychology, Amsterdam University
Medical Centers, Amsterdam, the Netherlands
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/)
https://doi.org/10.1016/j.jsxm.2022.01.001
INTRODUCTION
Mental health counseling of youth involves discussion and
evaluation of a variety of topics, including psychological func-
tioning, social functioning and family functioning. Private topics
such as sexuality and gender identity, though equally important,
may be discussed infrequently. This study aims to examine the
frequency of discussion of these private themes during consulta-
tion with mental health care providers, as well as contributing
and inhibiting factors.

J Sex Med 2022;19:421−429 421

422
Sexuality encompasses sexual behavior, gender identities and
roles, sexual orientation, pleasure, intimacy and reproduction.1
Sexual development begins in early childhood and accelerates
during puberty due to the release of hormones. Sexual and rela-
tional experiences are generally obtained in an age dependent
and progressive line of intimacy: at the start of puberty, most
adolescents have not yet kissed, while at the end the majority
have some sexual experience with others.2,3
The path of sexual development can be challenging for adoles-
cents in general. However, it may be more challenging for those
adolescents who have a psychiatric disorder because factors associ-
ated with the disorder (eg, low self-esteem, enduring mental
health-related stigma and social exclusion) may interfere with the
ability to form relationships and obtain sexual experiences.4,5,6,7,8
Problems related to sexuality can have a profound impact on qual-
ity of life in general.9,10,11,12 The available literature on sexuality
among youth with psychiatric conditions is primarily focused on
negative and risky behaviors rather than healthy sexual develop-
ment. Difficulties in relationship formation and sexual behavior
(such as deviant behavior) have been reported among children and
adolescents with Autism Spectrum Disorders (ASD).13,14 Rela-
tively high incidence of risky sexual behavior, sexually transmitted
disease and teenage pregnancy have been observed among
adolescents with attention deficit hyperactivity disorders
(ADHD).15,16,17 Sexual abuse during childhood and adolescence
is highly prevalent worldwide.18 Young people attending mental
health clinics are at risk of having been exposed to sexual abuse,
which is associated with the development of psychiatric
disorders.19,20 Structured assessment of trauma has been recom-
mended during mental health screening 20
Adolescents who struggle with personality disorder and
trauma are more likely than their peers to engage in sexual risk
behavior, teenage pregnancy, sexual harassment and re-
traumatization.21,22 Young people who have anxiety disorders
report more sexual dysfunction and relationship dissatisfaction
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
sexual dysfunction.25 Additionally gender identity and gender
nonconformity (see Box 1) are increasingly recognized as impor-
tant elements of youth development. In recent years, the number
of youth who struggle with their gender identity and seek help
related to this issue has increased.26 Adolescents who are in sex-
ual diversity groups (LGBTIQ: lesbian, gay, bisexual, transgen-
der, intersex, queer/questioning) are more likely than their
Box 1 Explanatory Words
Gender identity: a person's own experienced gender, which can cor-
relate or differ from a persons assigned sex at birth. Gender non con-
formity: a person who does not conform with the gender norms that
are expected. Gender inclusive language: speaking and writing in a
way that does not discriminate against a particular sex, social gender
or gender identity, and does not perpetuate gender stereotypes.
Bungener et al
nonminority adolescent peers to suffer emotional and physical
health concerns, and the suicide risk among adolescents in sexual
minority groups is 4.5 till 10 times higher than that of their
peers.27,28,29,30
Given these challenges during the developmental phase of
adolescence, youth with mental health disorders should have
opportunities to converse about these challenges and seek help if
necessary.31 A consultation with a mental health provider could
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be a designated setting to safely discuss these themes. In a sub-
question of a broader study on sexual dysfunctions among young
patients with mental health disorders, 87.4% believed that men-
tal health care providers should include sexual health care sup-
port as part of their services.25 However, besides this item no
data currently exist regarding (age-appropriate) communication
about sexuality and gender diversity between mental health care
professionals and youth with a psychiatric condition
Research in adult psychiatry has found that communication
regarding sexual topics is scarce: only 24% of psychiatry residents
(medical doctors specializing in psychiatry) reported that they
asked patients about sexual problems, and 30% reported that
they asked patients about sexual side effects when prescribing
medication.32 The majority of psychiatry residents (69%) felt
uncomfortable discussing sexual issues with patients.33
Sexuality can be a challenging topic for youth with psychiatric
disorders, and communication about sexuality with mental
health care providers could be a taboo
The present study aims to answer the following questions:
How frequently do mental health care providers (including psy-
chologists, psychiatrists/residents, group counselors and parent’s
counselors) communicate with their young patients and their
patients’ parents about sexuality and gender identity? What are
mental health care providers’ opinions and attitudes toward
this subject? What factors contribute to communication about
sexuality?
METHODS
Participants
Data were collected from May 2017 to September 2017
through an online survey, which was sent to a cohort of 786
mental health care professionals working in child and adolescent
psychiatry in the Netherlands. To obtain a representative sample
of health care professionals, 7 youth mental health institutions
(academic and non-academic) and 5 solo practices were con-
tacted by email for recruitment. The range of participant profes-
sions included: medical doctors (n = 42, psychiatrists and
residents) psychologists (n = 115, basic psychologists, healthcare
psychologists, clinical psychologists, psychotherapists, creative
therapists and education generalists) group counselors (n = 50,
sociotherapists and psychiatric nurses at inpatient clinics) and
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,

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

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of gender-nonconforming behavior and gender identity (6-point
scale; 0−100%). Participants were also asked whether they had
sufficient knowledge regarding psychological problems among
youth related to gender-nonconforming behavior and problems
with sexual orientation, and their knowledge about treatment
and referral options (yes/no responses).
Among professionals who prescribed medication (residents and
child/adolescent psychiatrists), communication about sexual side
effects was assessed using items regarding participants’ knowledge
about sexual side effects (yes/no response) and the frequency with
which participants provided information about sexual side effects
to their patients (including for antidepressant medications, stimu-
lant medications, antipsychotics and benzodiazepines). Additional
items included participants’ observed frequency of sexual side
effects and likelihood to provide a patient referral in case of side
effects (4-point scale; “almost always” to “never”).
Analyses
Descriptive statistics and an independent t-test were used to
describe participant demographic data. A one-way ANOVA was
RESULTS
Communication About Sexuality Among Mental
Health Care Providers
Table 2 presents the frequency of communication about sexu-
ality-related topics among the total sample of health care pro-
viders and for each of the different professional groups.
Significant differences were observed between the different
groups of professionals regarding their communication with ado-
lescents (F(3, 212) = 9.18, P = .00) and parents (F(3,
225) = 20.38, P = .00). Post-hoc analysis indicated that group
counselors discussed sexuality significantly less often with adoles-
cents than did medical doctors (-1.08 § 0.27, P = .00) or psy-
chologists (-1.12 § 0.22, P = .00). Parent counselors talked
more often with parents about sexuality than all other professio-
nals.
Just 17.1% of mental health care providers reported that they
discussed sexuality with at least 75% of their patients. Specifically,
19.9% of providers reported discussing this topic with most of
their adolescent patients, 14.0% with most of their patients’
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
sexuality were observed, in that psychologists communicated
about this topic more often (30.6%) than medical doctors
(12.2%; x2(1) = 4.72, P < .05). Group counselors communicated
about sexuality significantly less than participants in all other pro-
fessions (2.3%; x2(1) = 9.17, P < .05). No gender differences
were observed between male and female professionals in terms of
frequency of discussing sexuality-related topics (adolescents:
x2(1) = 1.78, P = .18; parents: x2(1) = 3.06, P = .080).
The vast majority of participants in all professional groups
(99.5%) reported that communication about sexuality with ado-
lescents was important. The majority of participants (93.7%)
considered the task of communicating about sexuality to be part
of their profession, and most participants (94.6%) reported that
they did not pay enough attention to this subject. No differences
were observed between professional groups regarding these
items.
The most common reasons participants reported that they did
not discuss sexuality with patients included “not thinking about
it” (33.1%), “the patient will be ashamed” (31.4%), “the patient
cannot handle a conversation about sexuality” (25.6%), lacking
time (22.7%) and the health care provider’s feelings of shame
(20.2%). In case sexuality was discussed, the topics that were
most frequently addressed included: being in love (86.0%), rela-
tionships (80.2%), sexual trauma (67.8%), sexual experiences
(65.7%), sexual risk behavior (56.6%), sexual orientation
(52.1%), deviant sexual behavior (21.1%), sexual harassment
(50.5%), sexual development phases (35.5%), sex and social
media (33.9%), gender diversity (29.9%) and sexual dysfunc-
tions (2.5%). No differences in responses were observed between
male and female mental health care professionals.
Conversations about sexuality-related topics were often initi-
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
was assessed, these conversations most often took place in fol-
low-up treatment (84.7%), at intake (45.0%) or in clinical group
counseling (10.3%). The majority of survey respondents had no
experience providing treatment or counseling for sexual problems
(75.1%) or providing a referral to a specialist for sexuality-related
topics (77.1%).
MEDICATION
A large majority (72%) of the medical doctors (residents
and psychiatrists) in the study sample rated their knowledge
level of sexual side effects as sufficient. However, 20.3% of
the doctors reported that they provided >75% of their
patients with information about sexual side effects when pre-
scribing medications; antidepressants (40.0%), antipsychotics
(34.0%), benzodiazepines (5.1%) and stimulants (2.4%). No
gender differences or differences between residents and psy-
chiatrists were observed.
J Sex Med 2022;19:421−429
425
Table 3. Communication about gender non-conform behavior and
gender identity
Gender non conformb Gender identityc
a
Frequencies N (%) N (%)
0% Never 49 (21.4) 59 (25.8)
1−5% 68 (29.7) 96 (41.9)
6−25% 65 (28.4) 47 (20.5)
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26−50 24 (10.5) 12 (5.2)
51−75 9 (3.9) 8 (3.5)
76−100 6 (2.6) 0 (0.0)
a
% of patients or parents where gender topics are discussed by mental
health care professionals.
b
Gender non conform behavior: behavior doens’t match the gender norms
that are expected.
c
Gender identity: a person's own experienced gender, which can correlate or
differ from a persons assigned sex at birth.
Communication About Gender Identity and Gender
Nonconformity
The findings presented in Table 3 indicate that mental health
care providers (who do not work at transgender clinics) do not
frequently talk about gender-nonconforming behavior or gender
identity. In the transgender clinic, all mental health care pro-
viders talked about these themes frequently. In the study sample,
21.4% of mental health care professionals had never spoken with
their patients about gender-nonconforming behavior, and
25.8% had never discussed gender identity issues with their
patients. Additionally, the professionals in the sample stated that
they had some knowledge of gender identity development
(58.6%), psychological problems that co-exist with gender-non-
conforming behavior (29.5%) and referral options for these
issues (12.3%).
DISCUSSION
This study examined communication about sexuality and
gender identity between mental health care professionals, their
adolescent patients and the parents of those patients. The find-
ings illustrate that practically all mental health care professionals
think sexuality and gender identity should be addressed but seem
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-
sumed feelings of shame experienced by the patient, lack of time
and the professional’s own feelings of shame. The majority of
participants reported that they did not communicate with their
patients about gender identity or gender nonconformity.
Almost all (99.5%) of the professionals in our study stated
that sexuality is an important topic to discuss with young
patients and an almost as large group of professionals (93.7 %)
indicated that they considered it to be part of their professional
duty. This finding echoes the arguments of various researchers
who have emphasized the importance of including sexuality in
426
youth mental health care.10,31,34 One even stated: Not asking
about these (sexual) experiences can be compared with not mea-
suring head circumference of infants during the first year of
life.31 We are not convinced that sexuality should be discussed
with all young people at all times. There are situations such as an
acute psychiatric situation (eg, severe manic episode or psycho-
sis), where it is less relevant. However, given that young people
receiving mental health care during the developmental phase in
which sexuality and relationships play a major role some form of
attention for these subjects is recommended.
Furthermore, the fact they are more vulnerable (due to a
higher chance of trauma in history18,19,20, sexual side effects of
medication31, and other reasons), it would be desirable if profes-
sionals create opportunities during treatment to engage in con-
versations about these topics with youth to support healthy
sexual development.
In the present study, youth mental health care providers
reported discussing sexuality frequently (stated as: with at least
75% of their patients) with 17.1% of their patients (19.9% of
adolescents, 14.4% of parents The incidence of sexuality-related
discussion is lower than that reported in adult psychiatry studies.
Voermans et al. reported that 43% of residents and psychiatrists
regularly addressed sexuality with their adult patients, and Rele
reported that 24% of psychiatric trainees routinely asked adult
patients about their psychosexual history.32,33 These findings
indicate that it is already difficult to address sexuality in adult
psychiatry, however, communication with young patients about
this topic may pose additional challenges for youth mental health
care professionals.
Few of the medical doctors (residents and psychiatrists) in this
study reported that they frequently (> 75% of their patients)
informed their young patients about sexual side effects when pre-
scribing psychotropic medications (20.3 %). This is less frequent
than the conversations reported by medical professionals in adult
psychiatry (antidepressants; 66.7% and antipsychotics; 40.0%).
32
The few studies on sexual side effects on youth receiving psy-
chotropic medication mirror the high prevalence of sexual dys-
function found among adult samples.10,11,25,35,36
Sexual dysfunction also occurs in people who have mental
health disorders and do not take medication; however, sexual
dysfunction can negatively affect medication adherence for those
who do take medication.37,38,39,40 Therefore, communication
about the sexual side effects of medication is essential to increase
patient adherence to psychotropic medication treatment and
should be initiated as part of standard protocol by medical
doctors.10,31,32,29
Gender identity and gender nonconformity were rarely
addressed among the present study sample: 25.8% of the mental
health care professionals had never spoken with their patients
about these subjects. Adolescence is pre-eminently a period of
identity formation, including gender identity. The number of
young people who are struggling with their gender identity is
Bungener et al
increasing. In the USA 1.8% transgender and 1.6% is question-
ing. This can remain undisclosed for a long period and psycho-
logical problems, including suicidality frequently occur
associated with these struggles.26,27,28,41Therefore, MHP work-
ing with adolescents could create a safe environment to enable
young persons to talk about their (gender) identity.26,27,28
Why is it so difficult to communicate about these topics with
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youth receiving mental health care? In order to understand the
underlying reasons for not discussing it, we looked at comparable
literature from adjacent fields, that of adult psychiatry and that of
general (not mental/psychiatric) youth health care. In our study,
a lack of awareness about this topic was most frequently given as
reason why providers did not talk about sexuality with their
patients. This is in line with literature describing a lack of knowl-
edge and practice among health care professionals.32,33,42,43,44,45
Recently, some medical, psychology and psychiatry universities
started with the implementation of sexual education and com-
munication skills in the standard curriculum.46,47,48
The second most frequently cited reason in this study was
concern about the patient’s supposed feelings of shame or dis-
comfort. Avoiding discussion about sexuality to protect the
patient from supposed discomfort has been described before in
the literature.45 Research in general (nonmental) health care
among young patients has found that some adolescent patients
do report discomfort with this topic: 99% of patients said it was
easy to talk to their doctor in general, but 57% said it was
uncomfortable to address a sexual problem with their doctor.
Feelings of discomfort are most likely to occur when there is no
understanding of the purpose of discussion, when young patients
are feeling judged or when the patients do not trust that the con-
versation is private.49 For LHBTIQ youth a lack of inclusive lan-
guage during healthcare visits may lead to feel a lack of
acceptance.42 A study of audio recordings of patients visiting
their general practitioner has indicated that inclusive language
(see Box 1) was rarely observed (3.3%), and noninclusive lan-
guage was predominant (48.%).42
It is possible that the supposed shame of the patient is in fact
the shame or discomfort experienced by the professional. In adult
psychiatry, 50−69% of psychiatrists and residents reported feel-
ings of shame around sexuality.32,33 In the current study, 20.2 %
of the participants experienced shame or discomfort. Qualitative
research in youth general health care settings has found that it is
easier for young patients to discuss gender identity and sexuality-
related topics if their health care provider is indeed comfortable
with such topics.28, 50
Lack of time has also been reported as a reason not to include
the topic of sexuality during health care visits. In conversations
between general practitioners (GP) and young patients, conversa-
tions of a longer duration were more likely to include sexuality
topics than shorter conversations.50,51 This is an interesting
result, since in general, conversations in psychiatric care tend to
be longer than those in GP visits. Moreover, previous studies in
J Sex Med 2022;19:421−429
Talking About Sexuality in Youth Psychiatry
adult psychiatry did not find a relationship between lack of time
and exclusion of sexuality topics.32,33
The present study has some limitations. Respondents were
asked to estimate their frequency of sexual communication,
which brings a risk of bias and may have provoked socially desir-
able answers. If this is the case, the percentage of respondents
who communicate about sexuality on a regular basis could be
lower than reported.
In the future, qualitative studies could address clinician and
patient perspectives in greater detail to understand the barriers
and facilitators of communication about sexuality in mental
health care.
In conclusion, almost all mental health care providers find it
important and their task to communicate about sexuality and
gender identity with adolescent patients. However, in practice
they seem to avoid these topics, due to a lack of awareness, time,
presumed feelings of shame of the patient and professional’s
shame. It would be advisable for professionals to initiate and
enable age-appropriate conversations about these topics, espe-
cially when prescribing psychotropic medications or screening
for sexual trauma.52
Corresponding Author: Sara L. Bungener, MD, PhD, Amster-
dam UMC, VUmc, Amsterdam, Noord-Holland, Netherlands.
Tel: +0642989828; E-mail: s.bungener@amsterdamumc.nl
Conflict of Interest: The authors report no conflicts of interest.
Funding: None.
STATEMENT OF AUTHORSHIP
S.L.B, L.P. and A.P. conceptualised the study, S.L.B and L.P.
performed the survey, I.B. curated the data, S.L.B analysed the
data and wrote the manuscript, L.P., I.B., A.P., A.L.C.d.V and
T.D provided expertise and feedback.
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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

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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