Erotic Transference and Countertransference in Sex Therapy

There’s a moment many therapists know, but few talk about out loud: a patient says something, or looks at you a certain way, or thanks you a little too warmly at the end of a session, and something stirs. Not necessarily desire exactly. Sometimes it’s flattery. Sometimes it’s discomfort. Sometimes it’s a flicker of attraction you would rather not examine too closely. And then you move on, because that’s what therapists do.

But in sex therapy, “moving on” is a harder trick to pull off. When your entire clinical territory is desire, arousal, intimacy, and the body, the erotic doesn’t politely wait outside the door. It’s already in the room. This makes erotic transference and countertransference, feelings of attraction, longing, or eroticism that arise between patient and therapist, not a rare occupational hazard, but something close to an occupational certainty.

This piece pulls together what a century of clinical writing, a handful of recent surveys, and a surprisingly small pile of hard data have to say about it: what it is, why it happens, how to work with it instead of around it, and where the field still has real blind spots. Consider it a map, not a manual.

 

Common, not scandalous

If you’ve ever felt attracted to a patient and quietly panicked about what that meant about you as a professional, you’re in very good company. A landmark 1986 survey of psychotherapists found that 87% had felt sexually attracted to a patient at some point: 95% of male therapists and 76% of female therapists (Pope et al., 1986). Only a small minority ever acted on it. Most just felt guilty, confused, or anxious about it, largely because almost nobody had trained them on how to handle the feeling.

Newer surveys tell a similar story. A 2022 study of nearly 550 psychotherapists found erotic feelings toward a patient to be fairly common and, notably, not inherently pathological (Stefana et al., 2024). Roughly seven in ten therapists in a Belgian sample reported finding a patient sexually attractive at some point (Vesentini et al., 2022). The takeaway across sixty-plus years of research is remarkably consistent: feeling it is normal; acting on it is the actual problem. Conflating the two is where a lot of unnecessary shame gets manufactured.

 

Where the idea comes from

Freud started this conversation in 1915 with his paper on “transference-love,” describing what happens when a patient falls in love with their analyst. His original take was fairly unflattering; he saw it as a kind of infantile resistance, a repetition of old childhood longings rather than anything “real.” For decades, that was more or less the official line: erotic feelings in therapy were a problem to be interpreted away, not a phenomenon worth sitting with.

That started to shift in the 1970s–90s. Blum (1973) drew an important line between erotized transference (intense, often disorganized, harder to work with clinically) and erotic transference (milder, more integrated, and useful material). Then came a pivotal cluster of papers, almost all published in 1994, that changed the field’s whole posture toward the topic. Jody Messler Davies’ “Love in the Afternoon” argued that erotic countertransference is co-created — arising out of the relationship itself rather than sitting solely with the analyst to manage and hide — and deserves the same open clinical curiosity as any other transference material. Glen Gabbard, around the same time, distinguished therapists who could contain and metabolize erotic countertransference constructively from those who acted it out destructively — a distinction that still underpins most modern ethics training.

In short: the field moved from “this is dangerous, suppress it” to “this is data, and suppressing it is often what makes it dangerous.”

 

Why it’s not just an “analyst problem”

Erotic transference isn’t confined to classical psychoanalysis on a couch. It shows up across modalities and populations:

• With trauma survivors, therapists working with sexual abuse history report a genuine mix of emotional responses (protectiveness, anger at perpetrators, empathy, and yes, erotic countertransference) sometimes in the same session (Tlali, 2022). Davies and Frawley’s 1994 work on treating adult survivors of childhood sexual abuse remains one of the most-cited texts in this entire literature, mapping out how trauma reshapes the transference-countertransference field.
• With adolescents, the literature gets thinner, almost conspicuously so. Brady (2018) points out that erotic transference and countertransference with teenage patients are barely written about, despite adolescence being the developmental stage where sexuality is actively forming. Brady suggests the clinical terms themselves, “erotic transference” and “erotic countertransference,” can feel too antiseptic, and proposes “erotic field” as a warmer, more accurate description of what’s actually happening in the room.
• In couples and psychosexual work specifically, therapists describe something closer to “dread” than desire: countertransference reactions to a couple’s stuck, anxious, or avoidant sexuality, which the therapist has to metabolize without becoming paralyzed by it (Abse, 2018; Rix et al., 2018).

 

What matters clinically: management, not suppression

Here’s where the research gets genuinely useful for practice. A 2018 meta-analysis by Hayes and colleagues pooled data across multiple studies and found something worth remembering: countertransference reactions themselves have a modest negative association with outcomes, but therapists who successfully manage their countertransference get measurably better outcomes than those who don’t (Hayes et al., 2018). The feeling isn’t the enemy. Unmetabolized, unexamined, unsupervised feeling is.

Little (2018) frames the task well: therapists need a strong enough therapeutic frame and boundaries to let erotic material surface safely, rather than either shutting it down reflexively or losing the frame entirely. A 2024 qualitative study of 116 therapists found three recurring themes when erotic transference showed up: it felt like a threat (to the work, to the therapist’s professional self-image), it required boundaries, and when handled well, it offered real growth, both for the patient’s insight and the therapist’s own development (Lans et al., 2024).

The consistent clinical advice across nearly all of this literature is to notice it, name it internally, bring it to supervision, and resist the urge to either act on it or pretend it isn’t there. Both extremes cause harm.

 

The ethics, plainly

This is the part every therapist already knows in their bones but is worth saying directly: feeling attraction is not a violation. Acting on it is. Sexual boundary violations remain the single most serious category of ethical infraction in mental health work, with historical incidence estimates in the 9–12% range among practitioners (Celenza, 2011), a sobering number that underscores why this topic deserves open discussion rather than embarrassed silence.

Jenks and colleagues (2020) offer a useful ethical scaffold, walking through how core principles such as autonomy, beneficence, nonmaleficence, fidelity, and justice apply specifically to romantic or sexual feelings in the therapy room. The throughline: rigid “don’t feel it” rules don’t protect patients nearly as well as trained, supervised, honest engagement with the feeling does.

 

Where the research runs thin

In the interest of intellectual honesty (and because you’re a professional audience who’ll want to know this before citing anything): the evidence base here is long on theory and case material, and comparatively short on hard empirical outcome data. Much of what we “know” comes from single-case psychoanalytic writing rather than controlled research, which isn’t wrong, but it does mean the field’s confidence sometimes outpaces its data.

The most striking gap for readers of this platform specifically: almost nothing in the literature treats erotic transference and countertransference as a distinct concern within certified sex therapy or clinical sexology, with one recent exception. In 2023, Gewirtz-Meydan, Lans, and Reuveni built the first validated tool for it — the Therapists’ Attitude toward Sexual and Erotic Feelings Scale, or TASEF — and published it in the Journal of Sex & Marital Therapy (Gewirtz-Meydan et al., 2023). It’s barely been picked up since. Everything else tends to live inside general psychotherapy or psychosexual couple therapy rather than sex therapy proper. Given that sex therapists work more directly and explicitly with desire and the body than almost any other clinical specialty, that’s a real and slightly surprising blind spot, and exactly where this field needs to catch up with a tool it already has.

 

The short version

What this actually calls for is structure, not more awareness: supervision hours in psychosexology training that name erotic and eroticized transference explicitly rather than folding them into a general ethics module; a deliberate taxonomy for sex therapy and supervisors willing to raise the subject first.

None of that requires treating attraction as the danger. 87% of therapists have felt it at some point (Pope et al., 1986); a much smaller group, 9–12%, ever act on it (Celenza, 2011). What separates those two groups isn’t willpower, but whether anyone taught them to notice the feeling before it became a decision. That’s a curriculum question, not a personality trait.

That’s also, practically, what a platform like IOSS is for. A community built around sexology has the standing, and arguably the obligation, to be the place where this gets taught outright rather than left to whichever supervisor happens to bring it up unprompted. Supervision tracks that name erotic and eroticized transference in the syllabus, not folded into a general ethics module. Case consultation groups where a clinician can say, “I think I’m feeling this,” before it turns into a crisis. None of that requires a new theory. We are trained to listen for and interpret patients’ silences, but not always our own, and erotic transference and countertransference ask us to do both.

By Marc Bou Sleiman

 

If you want to know more about transference and countertransference, watch:

Management of Transference and Countertransference in Sexual Therapy, by Hester Pastoor

 

References

Abse, S. (2018). Sexual dread and the therapist’s desire.

Blum, H. (1973). The Concept of Erotized Transference. Journal of the American Psychoanalytic Association.

Brady, M. (2018). Braving the erotic field in the treatment of adolescents. Journal of Child Psychotherapy.

Celenza, A. (2011). Sexual Boundary Violations.

Davies, J.M. (1994). Love in the afternoon: A relational reconsideration of desire and dread in the countertransference. Psychoanalytic Dialogues.

Davies, J. & Frawley, M. (1994). Treating The Adult Survivor Of Childhood Sexual Abuse: A Psychoanalytic Perspective.

Freud, S. (1915). Observations on Transference-Love.

Gabbard, G. (1994). Sexual Excitement and Countertransference Love in the Analyst. Journal of the American Psychoanalytic Association.

Gewirtz-Meydan, A., Lans, O., & Reuveni, L. (2023). Lo(u)st in Therapy: Development and Psychometric Evaluation of the Therapists’ Attitude toward Sexual and Erotic Feelings Scale (TASEF). Journal of Sex & Marital Therapy.

Hayes, J., et al. (2018). Countertransference Management and Effective Psychotherapy: Meta-Analytic Findings. Psychotherapy.

Jenks, D.B., et al. (2020). Breaking Hearts: Ethically Handling Transference and Countertransference in Therapy. American Journal of Family Therapy.

Lans, O., et al. (2024). Addressing the elephant in the room: how erotic transference is identified and understood in therapy. British Journal of Guidance & Counselling.

Little, R. (2018). The Management of Erotic/Sexual Countertransference Reactions. Transactional Analysis Journal.

Pope, K., et al. (1986). Sexual attraction to clients: The human therapist and the (sometimes) inhuman training system. American Psychologist.

Rix, S., et al. (2018). Loss of desire and therapist dread.

Stefana, A., et al. (2024). Erotic Feelings Towards Patients in the Psychotherapy Session. Sexual Abuse.

Tlali, T. (2022). Therapeutic tool or a hindrance? A phenomenological investigation into the experiences of countertransference in the treatment of sexually abused children. Indo-Pacific Journal of Phenomenology.

Vesentini, L., et al. (2022). Intimacy in Psychotherapy: An Exploratory Survey Among Therapists. Archives of Sexual Behavior.