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Discourse around desire and intimacy when working with substance misusers is often characterized by issues of social control, repression and silence. It appears that intimacy and sexual desire are rarely discussed or worked with in the substance misuse field and this is potentially an under-researched area of practice within health and social care. Dominant discourse within the substance misusers’ field perpetuates a lack of attention to these essential aspects of the human condition. This paper attempts to raise awareness of these issues and challenges some of the many established assumptions held. It also seeks to identify how practitioners might begin to deconstruct these dominant discourses, and start to recognize issues of intimacy and sexual desire as legitimate needs related to human rights and wellbeing. While this paper is focused on the substance misuse field, we argue that the concepts raised may be transferable and of interest across the health, social work and social care arena. Exploring these issues within the substance misuse field helps to consider the more general context of why issues of intimacy and sexual desire are neglected in professional practice. Practitioners are challenged to consider how these issues might be enhanced within all aspects of the professional/service user relationship and the essential skills and knowledge required in order to provide more holistic and culturally competent practice.