Sexual difficulties

This is among the hardest things to raise with anybody, and one of the more common reasons people quietly do not come at all. So, at the outset: our clinicians have these conversations as a routine part of their work, and nobody here will be surprised by yours.

People describe a wide range of things. Desire that has changed — gone, or arrived unevenly, or become a source of conflict between two people who each believe the other is the problem. Difficulty with arousal or performance, and then the anticipation of it, which begins to matter more than the difficulty itself. Pain. Avoidance that started as one awkward evening and became a pattern neither person mentions. Or difficulty that arrived alongside something else entirely — a medication, a bereavement, an illness, a new baby.

Some come because of what it is doing to a marriage rather than the difficulty itself. Some come alone and have told nobody. Some come after a doctor found nothing physical. In Karachi there is a particular silence around this: people who discuss anxiety or low mood readily will not begin this sentence, and often carry it for years. Arriving late is ordinary here and is not held against anybody.

Recognising yourself in a paragraph on a website is not the same as knowing what is going on. This page describes; it does not assess you, and there is nothing here to score yourself against.

There is no threshold you have to cross before you are allowed to ask, and no version of this that is too small to bring.

What a clinician pays attention to is duration and cost — the same two things that matter for any other presentation. Something that has been the case for months rather than one hard fortnight. Something that has begun to change what you do: avoiding a partner, avoiding the conversation, arranging your life around not facing it. It also matters when it has become a source of blame between two people, or when you have been checked medically and want to understand the part that is not physical.

Only a qualified clinician can tell you what is going on — a website cannot. What this page can tell you is that the question is a reasonable one to bring, and that it is brought here far more often than most people imagine.

PHC is an assessment-first practice, and that matters more here than almost anywhere. Sexual difficulty can be physical, psychological, relational, medication-related, or several at once, and the order in which you work that out changes what happens next.

1. An initial sessionWe ask what has been going on, for how long, and what it is costing you — in your own words, at your own pace. Nothing is administered before this conversation.
2. Working alongside a doctor, not around onePHC's clinicians are clinical psychologists. They do not prescribe and do not carry out physical examinations. Where the picture suggests a medical cause worth investigating — including a medication you already take — we say so plainly and recommend a doctor alongside the psychological work, not instead of it.
3. Emotional assessment where it is indicatedWhere the difficulty sits alongside low mood, anxiety or long-running stress, a structured screening of emotional functioning helps separate what is driving what. It is used because it is clinically warranted, not as a matter of course — you will not be given tests you do not need.
4. Therapy, matched to who is comingFor an individual the work is usually sexual psychotherapy, sometimes with CBT where anticipation and avoidance have become the larger part of it. Where both partners want to attend, it may be taken up within marriage and couples counselling. Sessions are 50 minutes, at our DHA clinic or in PECHS, or online.
5. What is written down, and who sees itWhat you say in a session is confidential. It is not discussed with your family, your employer or anyone else without your agreement, and notes are not shared with a partner — including one attending sessions with you — without your consent. Like every psychologist anywhere, ours work within limits set by law and by professional duty of care: narrow, defined in advance, and explained to you rather than sprung on you. They are set out in full in what confidentiality does and does not cover.

• Marital conflict
• Low self-esteem
• Sexual psychotherapy at PHC
• Marriage and couples counselling