A person’s sexuality exerts a powerful influence on their needs, desires, roles, social relationships and personal identity. This study, explored occupational therapists’ reasoning and practice in relation to the work they do (or do not do) with clients for whom sexual expression has become problematic. The lens used to explore reasoning and practice was a key conceptual framework adopted by occupational therapists, the occupational perspective of health, which considers humans need to do, be, become and belong. Using a qualitative, phenomenographic approach, 16 occupational therapists from across Australia were interviewed to understand the qualitatively variable ways in which they reasoned about practice in relation to the sexual needs of their clients. Four related, layers of ‘conception’ are presented. At a foundational level, we describe how participants conceived of their practice role in relation to assisting people in the doing aspect of sex(uality). At the next, more complex level, participants appeared to conceive of practice in relation to their clients’ being as a sexual person. The next conception related to how therapists think about their clients in their becoming as a sexual being and finally, in their belonging as a sexual being. These conceptual categories, derived both theoretically and empirically are presented as a hierarchically aligned framework, the occupational perspective of sexuality (OPS). While generated from a study of occupational therapists’ reasoning, the OPS has potential to enable a broader, more holistic consideration of sexuality, assisting health care professionals and educators to better understand the ways in which they may address their clients’ needs to do, be, become and belong to their sexuality.