The British Skin Foundation sat down with Clinical Psychologist and Psychosexual Therapist Dr Natasha Langan to learn about psychosexual health and the impact skin conditions can have on sex and relationships. 

Dr Natasha Langan, Clinical Psychologist, Psychosexual Therapist and Psycho-Sexologist

What does a clinical psychologist and a psychosexual therapist do, how do you become one, what does it allow you to do? 

A clinical psychologist is trained to assess and offer evidenced based interventions for a broad range of psychological presentations across the life span. You will need to complete an undergraduate degree in Psychology and undertake relevant work experience to gain entry to a Doctorate in Clinical Psychology. People also may do further postgraduate study to help improve their prospects of getting onto clinical training. Typically, it can take 7 years of studying plus years gaining experience before entering clinical training. In the UK Psychologists are regulated by the HCPC.

A psychosexual therapist has done further advanced specialist training to work with individuals/couples with a range of sexual problems. To train as a psychosexual therapist you will need prior training as a psychologist, psychotherapist, counsellor, or health professional in a related field. In the UK, training is typically part-time over a two-year diploma alongside supervised work experience in a psychosexual therapy clinic. In the UK and Ireland, psychosexual and relationship therapists are regulated by COSRT. 

So, psychologists work with a broad range of psychological problems and if experienced can work with sexual problems. Psychosexual therapists are specialists in the area of sexual problems.

What does the term ’psychosexual’ mean? 

Psychosexual therapy is a specialist psychotherapy applied to the area of human sexual behaviour and sexual problems.

What do you see as the link between skin and psychosexual health?  

I think this is a really important area to explore and consider. Skin is the largest organ in the body and it is also plays a big role in the sensory experience of sexual intimacy and pleasure.

In psychosexual therapy services we may see patients that are presenting with skins conditions in the genital area and this can result in anxiety about sex, low desire, pain during sex (dyspareunia), pelvic floor tension (vaginismus) and orgasm problems.

A common skin condition seen in PST clinics is Lichen scleriosis, an inflammatory skin condition of the vulva which can result in sex being uncomfortable, painful or make penetration impossible. Dermatologists may refer patients for psychosexual therapy in the NHS.

Living with a skin condition may lead to concern around skin and body appearance, perceived sexual attractiveness, and confidence. This could lead to feelings of anxiety, stress, and shame which we know will have negative effects on sexual arousal, pleasure and sexual intimacy. 

We also know that people who are anxious about sex may avoid sex and relationships and/or might use alcohol or drugs to relieve anxious feelings before sex.

Are concerns around psychosexual health caused by skin conditions linked only to skin conditions impacting the genitals?

No, we know that living with a skin condition can negatively impact emotional and psychological wellbeing. We know that one of the symptoms of depression is a loss of interest in sex. If you are anxious or feeling low about living with a skin condition, it may be that your sexual wellbeing is impacted.

Sexual health and wellbeing is an important part of general wellbeing but unfortunately can get overlooked in health settings. You may have not been asked about your sex life or how you feel about it. It’s important to reflect on the impact of living with a skin condition on your sexual well-being. Everyone’s experience is different. 

You might ask yourself questions such as:

• How does my skin condition impact on how I feel about myself as a sexual person, my sexuality or sexual wellbeing?
• Does my skin condition negatively impact sexual pleasure such as pain or discomfort during sex?
• Do I focus on thoughts about my skin condition or how a partner may perceive me during sex and how might this impact on sexual pleasure?
• If sex is positive and pleasurable, what are some of the things that help you feel good e.g. on your own, masturbation or using a vibrator.
• Or if you’re with a partner, are they sensitive, understanding, caring.

A famous sex researcher, Emily Nagoski, talks about ‘brakes and accelerators’. What are the factors that put a ‘brake’ on sexual desire and arousal such as pain, anxiety, an inconsiderate partner; and what are the things that help rev up your desire, arousal and pleasure e.g. foreplay, fantasy, feeling confident, a kind partner.

It’s good to spend some time considering your own ‘brakes and accelerator’.  Self-knowledge and awareness will help you communicate your sexual needs. You deserve to feel good about your sexuality, sexual self and wellbeing…. it’s a human right.

At what point would someone who is struggling with their mental and psychosexual health due to a skin condition come to see you?

I would encourage anyone struggling to make an appointment and seek support. I have worked with people that have struggled for years in silence before seeking support due to shame and stigma. This can lead to someone feeling isolated and further impact on mental and sexual wellbeing.

It’s important to emphasise that psychosexual therapy is for people regardless of relationship status, age, gender and sexual identity.

NHS services psychosexual therapy services are commissioned to work with people 16 years and older, so it is important to say that I have worked with patients that are 16 to patients in their 80s.  

What can someone whose wellbeing is negatively impacted by their skin expect from an appointment with you? 

First off, the initial appointment is about getting to know you and what’s brought you for an appointment. It is also a chance for a patient to get to know me, how I work and ask any questions.

As a psychosexual therapist we understand that talking about sex and intimacy can bring up uncomfortable feelings such as anxiety, fear, shame, stress, disgust. So the appointment is there to explore how someone might feel opening up about this intimate area of their lives. As a psychosexual therapist we are trained and skilled in helping clients feel safe to talk about sexual problems and it’s important to remember it’s what we’re trained to do and we work with lots of patients/clients so it’s hard to shock us.

Our hope is to create a safe and non-judgemental space to talk openly about sexual wellbeing and sexual problems so as to make sense and understand what they mean for you in the context of your life and relationships. 

The assessment process can be comprehensive and take a number of sessions. We will ask questions about you, your life, if you’re in a relationship and/or relationship history, medical and mental health history. We will ask about the sexual problem, your understanding of it, and how it impacts you and your relationship (if you are in one). To inform our assessment, a relationship and sexual history will be taken, this information helps us assess and understand what factors may be contributing to and maintaining difficulties such as poor sex education, sexually conservative family, bullying, negative sexual experiences, birth trauma.

Finally, we want to explore together your hopes for therapy and what would life look like if therapy was helpful.

The assessment process will help develop an understanding or formulation of sexual difficulties and inform the treatment plan going forward.

Do you have any tips to help people get the most out of their appointment with you? 

Make that appointment and show up. Sometimes that is the hardest part, anxiety can lead to us engaging in avoidance behaviours so take that risk. 

If it feels comfortable and not too anxiety provoking it may be helpful to spend some time reflecting on your experience of sexual difficulties with questions like: how long has it been a problem, what have you tried that helped, what has not helped?

If you want to find out more information on psychosexual therapy in the UK and Ireland the College of Sexual and Relationship Therapists (COSRT) website have lots of information

COSRT: https://www.cosrt.org.uk

Institute of Psychosexual Medicine: https://www.ipm.org.uk/

NHS information: https://www.nhs.uk/common-health-questions/sexual-health/what-does-a-sex-therapist-do/

Do you have any advice for people whose skin is affecting their mental and sexual wellbeing? 

You are not alone. This campaign is about creating greater awareness that skin conditions impact on mental and sexual wellbeing and it’s important for us to be having this conversation.

If you have concerns, speak to a professional, don’t suffer alone. There are people that will understand your experience and help you change your relationship with body and skin compassion. 

Self-compassion and body and skin compassion is an important area to explore. We may not feel compassionate, but we can plant seeds and cultivate compassion to be with ourselves, with our skin, with our body in a different way.

Is there a ‘one size fits all’ therapy for someone with a skin condition who is struggling with their sex life? 

No. Everyone is different. Meston and Buss (2007) did a study on why humans have sex and they found 237 reasons. Going back to Nagoski’s analogy of ‘brakes and accelerators’ everyone will have a different experience of brakes and accelerators. 

However, I do think that positive sex education is a central part of psychosexual therapy.

I also think it’s important to recognise the cultural messages we receive about beauty and attractiveness in our culture, and what messages we receive about our skin directly or indirectly. The skin we see on beauty magazines, TV, Films, and porn is typically smooth, hairless and blemish free. We do not see a wide range of skin diversity and skin conditions in the media.

We need to be able to take a step back and critically evaluate the messages we receive so that we can challenge them. The beauty industry is built on our insecurities and vulnerabilities. It is not our fault that we may find it hard to be self-accepting and experience body and skin compassion but we can start to cultivate a different relationship with ourself, including our skin, based on compassion.

Self-compassion and compassion informed psychotherapy will be an important foundation of any therapeutic work.

Dr Natasha Langan is a clinical psychologist and accredited psychosexual therapist, and co-founder of Norma, a dynamic digital educational platform for vaginismus and dyspareunia.

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