What Every Mental Health Professional Needs to Know About Sex
Stephanie Buehler, MPW, PsyD, CST
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Buehler, Stephanie (Stephanie J.)
What every mental health professional needs to know about sex / Stephanie Buehler, MPW, PsyD, CST. pages cm
Includes bibliographical references and index.
ISBN 978-0-8261-7121-4 (alk. paper)
1. Sexual health. 2. Sex therapy. 3. Sexual abuse victims—Rehabilitation. 4. Older people—Sexual behavior. I. Title.
RA788.B84 2014 613.9—dc23
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12. Sexual Recovery in Childhood Sexual Abuse Survivors 163
13. Sexual Pain Disorders 175
14. Sexuality and Reproduction 189
15. Sexuality and Medical Problems 201
16. Sexuality and Aging 217
17. Problematic Pornography Viewing Behavior 231
18. Alternate Sexual Practices 241
Part III: e th ICS and PraC t IC e of Sex t hera P y
19. Ethical Management of Sex Therapy Casework 253
20. Sex Therapy: Now and in the Future 263
Bibliography 269 Index 295
Foreword
When I speak at colleges about sex, I often start by asking students in the audience “How many of your parents told you what a clitoris is when you were growing up?” In an audience of 300 students, perhaps five will raise their hands. When I ask “How many of your parents explained to you what masturbation is or told you what orgasms are?” Ten or fifteen hands will go up. These are students at some of the top colleges who were raised by some of the smartest parents on the planet during the 1990s—not the 1950s.
When parents are not comfortable giving their children words for some of the most powerful physical and emotional experiences they will have in life, a veil of secrecy is created around the subject of sex that children carry with them into adulthood. This is why there is such a great need for a book like What Every Mental Health Professional Needs to Know About Sex. It doesn’t matter if the therapy we do is cognitively based, psychodynamic, interpersonal, or experiential, this book explores aspects of sex that are essential for therapists of all orientations to know.
Sex is an important part of most people’s lives, yet few mental health professionals receive any instruction about sex other than learning how to report suspected abuse. As a result, we aren’t always comfortable talking about sex and sexual pleasure with our patients. While reading this book won’t turn us into Kinseys or Masters and Johnsons, it will help us to relax more and to listen better. And that, in itself, is an important accomplishment regardless of how much or how little familiarity we have with sex education and sex research.
I have written a 1,200-page book on sex that is used in dozens of college and medical school sex-education classes. I have also read countless studies on sexual orientation, gender, pornography, paraphilias, sexual pain, low sex drive, high sex drive, casual sex, pedophilia, and the physiology and neurology of sexual response. Yet when I am with a patient or when a fellow mental health professional is consulting with me about a patient’s sexual issues, the most important thing I can do, besides being kind and caring, is to listen without making judgments. This is not always easy when you are raised in a culture with no shortage of shame-based messages about sex.
For example, consider our perceptions about women versus men when it comes to casual sex. Few of us would haul out our DSM-5s when a male informs us he has had 10 or 15 lifetime sexual partners. But if a woman has had 10 or 15 partners, or 20 or more, many of us would assume she was abused as a child, or she’s bipolar or borderline, or she’s a “sex addict.” And what if she enjoys having threesomes, or she asks her partner to spank her or to act out rape fantasies? What if she wants sex way more than her partner does?
This book was written by a highly experienced and sensible mental health professional who encourages readers to listen and think rather than to automatically pathologize or apply assumptions about sexual behavior that are 50 years out of date. It reminds us that sexual behaviors that could reflect a psychological struggle for one person might reflect psychological health for another. One of our jobs is to evaluate which is which.
One of the biggest challenges we face in evaluating sexual behaviors is how multifaced sex can be. Sexual feelings often begin as an erotic tension somewhere within our psyche or soma. They are then sifted through the labyrinth of our cognitive, cultural, and religious beliefs. When something is going wrong sexually, there are multiple layers where the problem can reside. I can’t imagine trying to help a patient sort through sexual issues without knowing what Dr. Buehler explains in the pages that follow.
And finally, I want to caution you about the current state of sexual knowledge and sexual research: Our knowledge of human sexuality remains elementary. Researchers are still struggling to define what women’s sexual orientation is and how it develops over the life span. Several of the top researchers are questioning the validity of the state-of-the-art fMRI brain studies about sexual behavior that the media loves to sensationalize and therapists love to quote. And it’s difficult to know if studies about sex and relationships apply to anyone besides the students in college psychology courses who are getting extra credit for participating in them.
Fortunately, we have Dr. Stephanie Buehler’s very thoughtful, approachable, and well-written book to help us with this process.
Paul Joannides, PsyD Author of Guide to Getting It On!, Seventh Edition
Preface
An endocrinologist with whom I once ran an integrated wellness center encouraged me to become a sex therapist, explaining that many of her patients request hormone testing because they had no sex drive. “But,” she said, “It is hardly ever their hormones that need adjusting.” I already had a background in treating people with chronic illness, and I understood right away that sexual problems were, perhaps, the ultimate expression of mind/ body symptoms. But how, I wondered, did one become a sex therapist?
One thing I knew for certain, the 10 hours in human sexuality that I was required to take to become a psychologist wasn’t anywhere near what I needed to know to talk to our shared clients about sex. I hadn’t learned much of anything in those 10 hours, except that there existed some mighty peculiar old sex education films and that many therapists in the audience were squeamish about sex. I wasn’t squeamish at all. I grew up in a liberal household in Los Angeles during the sexual revolution. Nothing offended me. But if I was going to truly hang out my shingle as treating sexual problems, I was in sore need of education and training.
Like many psychotherapists—who tend to be an introverted bunch—my first stop was to do some background reading. I chose a book online and as soon as it arrived I sat down to read, highlighter in hand. It wasn’t long before I closed the book, my mind reeling. It wasn’t because there was anything wrong with the writing itself. All of the contributing authors appeared to know their topic well. However, I still had no sense of “This is how to do
sex therapy.” I felt rudderless, adrift in a sea of technical language, with bits and pieces of various theories floating past like flotsam and jetsam.
Perhaps joining an appropriate organization might help me, I reasoned. I joined the American Association of Educators, Counselors, and Therapists and learned they had a certification process that included education and supervision. I chose Stephen Braveman, MFT, as my supervisor, and through his patient guidance and generous spirit (he sent me away with a duffle bag of materials on human sexuality), I began the 2-year trek to learn all I could to be an effective sex therapist.
Along the way, I received an entirely different education. First, colleagues and other professionals questioned my choice to become a sex therapist. Wouldn’t I be dealing with pedophiles and other pariahs? Second, some confused me with a sexual surrogate, a type of person who operates under the legal radar to teach people about their sexuality in a way that a professional license prohibited, for example, touching clients or having them examine bodies, both their own and that of the surrogate. Third, it struck me again and again how ludicrous it was, with all my education, that none of my college professors at the graduate level had ever really talked about sex. Why didn’t I know anything about the connection between eating disorders and sexual problems? How come I had never heard of painful sex and what to do about it? Didn’t I need to know how to assess persons who had been sexually abused about their current ability to function normally in their adult relationships?
Additionally, I began to pay attention to what clients said when they found my services. If they were referred by another therapist, it was often because the therapists “didn’t ‘do’ sex.” If they had been in therapy but were self-referred, it might be that they felt the therapist would be uncomfortable if they brought up the topic. Others were in therapy for years, but since the topic never came up, they never said anything. It was only when they realized that all the time and money they were spending had zero effect on their sexual pleasure that they searched for someone who would help them with the “real” problem.
I held two feelings about this. On one hand, I was happy that I received appropriate referrals. On the other, I was upset that other therapists added to the client’s shame about sex. By refusing or neglecting to ask about the client’s sex life, therapists reinforced the cultural message that “nice people don’t talk about sex.” But if people (nice or not) can’t talk about sex in the therapist’s office, where can they talk about it? Clearly something needed to change.
Back I went to thinking about my own evolution as a therapist. Information about treating sexual problems, I knew, was difficult reading. Few of the books take the therapist by the hand and lead them through the entire process of assessment and treatment from the moment of the intake call through termination. None of them deal with one of the most important issues of all: the sexuality of the therapist. Unless the therapist is comfortable with sex,
there would be no discussion of the topic in the therapy office. That fact alerted me that if I were to write a book on how to do sex therapy, I needed to start there, with helping the reader to make sense of what sexuality is and how to understand one’s own development, experiences, thoughts, attitudes, and beliefs about sex.
In your hand or on your screen, you have the text I envisioned for every therapist to have as a reference on his or her bookshelf. Whether you want to embrace sex therapy as a niche for your practice, or you want to be a therapist who “does” sex, my hope is that What Every Mental Health Professional Needs to Know About Sex will be a clear, pragmatic entrance into helping clients of all kinds resolve sexual concerns—a boat of sorts to help you navigate what can be a confusing area of human experience. I also hope that it will become a book you can turn to again and again when a client presents with a sexual concern to remind yourself that there exists an approach and information to calmly tackle common, and uncommon, sexual problems.
Human sexuality is perhaps one of the most complicated on the planet. Shrouded in secrecy, regulated by religion and law, and assigned meanings from original sin to the ultimate expression of sacred joy, sexuality can perplex even the wisest therapists. Sexuality is often a topic ignored in graduate programs in psychology, marriage and family therapy, and social work. In California where I practice, a psychologist is required to merely complete 12 hours (not course hours, hours) of instruction in sex therapy. This training was disembodied, that is, it had no connection to the 4 to 5 years of coursework learning about all other aspects of the human mind.
What Every Mental Health Professional Needs to Know About Sex is a straightforward, plain-language book designed to take the therapist who knows very little or who might be uncomfortable about sex, to a place of knowledge and competence. To accomplish this, Part I: The Courage to Treat Sexual Problems begins in Chapter 1 with a rationale regarding the reasons why all mental health professionals need to be able to address clients’ sexual concerns, especially the fact that our current social climate has raised clients’ expectations about pleasure. In Chapter 2, the reader will find topics concerning one’s own sexuality, including overcoming any associated shame and guilt related to sexual behavior, improving attitudes toward sexual pleasure, and embracing sexual diversity—not only the LGBTQ community, but sexuality in those who are ill or aging, or who engage in alternative sexual practices, for example, fetish behavior. Psychosexual development and the physiology of sex are covered in Chapter 3, while Chapter 4 is an examination of definitions of sexual health generated by various experts and organizations.
Part II: Assessing and Treating Sexual Concerns begins with an introduction to the thorough assessment of sexual problems that relies on two models and that forms a core part of the book. The first is Annon’s PLISSIT model, described in detail in Chapter 5; the second is an ecosystemic framework for
understanding and solving a client’s symptoms across different contexts. The PLISSIT model is ideal for a mental health professional at the early stages of treating sexual problems, as it guides the professional in deciding whether the presenting problem will benefit from psychoeducation and recommendations, or if more intensive, long-term therapy will be required. The ecosystemic framework, based on the work of Bronfenbrenner (1977), is an expansion of the biopsychosocial model as it includes interactions between two systems, which in the case of sex therapy relates to the frequency that couples present for treatment. A thorough sexual assessment is included, to use when it is determined that the presenting problem will require more intensive work.
The next two chapters cover women’s and then men’s common sexual complaints as they pertain to the individual, their biological make-up, development, relationship, and culture. Chapter 5 on women’s sexual problems covers sexual aversion, which occurs in both men and women. Chapter 6 includes delayed ejaculation, a problem once considered rare but is on the upswing as some men desensitize their arousal levels by viewing pornography, as well as the fact that people’s expectations of men as they age have increased. Both chapters include informational worksheets for the client’s— and therapist’s—benefit.
Addressing common sexual problems in couples explodes the myth that by fixing the couple’s relationship, their sex life will automatically improve. In fact, even couples that get along sometimes have sexual problems. As the therapist will learn in Chapter 8, whether the relationship is blissful or chaotic, most couples benefit from good sexual information; improved communication about sex; encouragement to explore the boundaries of their sexuality; and suggestions to help them. The most common problem is a discrepancy in sexual desire, which requires the therapist’s problemsolving skills to help the couple to stop blaming one another and learn how to derive solutions when the problem is sex.
Chapter 9 includes material I have not yet seen in any other book for therapists on the topic of treating sexual complaints: helping parents address their concerns about their children’s sexual development and answering their children’s questions about sex. The chapter also provides a framework as to when to refer to a specialist for evaluation of atypical sexual behavior or development. The entirety of Chapter 10 is devoted to understanding the needs of LGBTQ clients who may, ironically, have suffered because of their parents’ lack of information about sexual orientation.
Good mental health is essential to good sexual health, while mental illness can contribute to sexual dysfunction. In turn, feelings of guilt, shame, and sexual inadequacy can sometimes lead to mental health problems. In 2010, I wrote a ground-breaking book entitled Sex, Love, and Mental Illness: A Couple’s Guide to Staying Connected in which I addressed the effects of depression, anxiety, substance abuse, eating disorders, AD/HD, and other
disorders on the individual’s ability to function sexually and in a relationship. Chapter 11 is a broad summary of this review of the literature, while Chapter 12 provides an in-depth guide to understanding and treating sexual problems in adults related to sexual abuse experienced as a child or teen.
Chapters 13 to 16 are related in that they each cover an aspect of sexuality that is intimately tied to biology. Chapter 13 covers the effects of pelvic and genital pain on sexuality in men and women, which affects large numbers of people who sometimes have great difficulty finding appropriate treatment, lending to their suffering. In Chapter 14, therapists will learn what happens when recreation meets procreation, or how sexuality is affected by infertility. Sexuality can also be affected by all kinds of medical conditions, from diabetes to spinal lesions and paralysis, which is the topic of Chapter 15. The effects of aging on sexuality and relationships are the focus of Chapter 16.
Rounding up Part II, Chapters 17 and 18 explore what happens when people traverse conventional or expected boundaries, with Chapter 17 focusing on sex and the Internet, and Chapter 18 on paraphilias, also known as “alt sex” (as in “alternative”). Though sexual images have seemingly been in existence since ancient cultures constructed phallic and other fertilityrelated symbols, there has been an explosion in sexual imagery of all kinds since the dawn of the Internet. The enormous availability and variety of pornography has both helped (people can indulge in fantasy material in private, such as looking at people having sex while wearing latex or furs) and hurt in that viewing pornography may drain sexual energy away from a primary relationship. Meanwhile, those who practice alt sex need all kinds of care and support from therapists, from absolution from shame to helping them accept and perhaps participate in their partner’s erotic life.
Part III: Ethics and Practice of Sex Therapy wraps up the book with Chapter 19 on the ethical challenges of working with people who have sexual concerns, including respecting boundaries regarding touch; managing romantic or sexual transference and countertransference; managing secrets in conjoint therapy; and considering special topics such as treating people whose sexuality differs from one’s own and the effects of the field of sexual medicine on sex therapy. Finally, Chapter 20 completes the book with a look forward toward the future of sex therapy and the integration of sex therapy into one’s practice.
As with any book, there were some challenges presented. One challenge was the unwieldy term “mental health professional” used in the book’s title. Rather than shortening the term to “MHP,” which seemed impersonal, I most frequently use the term “therapist” to refer to the variety of people working in the helping profession. Both “mental health professional” and “therapist” refer to psychiatrists, psychologists, psychiatric nurses, social workers, marriage and family therapists, and professional counselors, including those medical providers who discuss sexual problems with their patients.
Another challenge was the use of gendered pronouns. As much as possible, I have used the word “partner” rather than “man,” “woman,” “husband,” “wife,” and so forth. Although gay, lesbian, bisexual, transgender, and queer (those individuals who do not identify strictly as male or female, or who question their orientation) roles and relationships are not strictly analogous to traditional heterosexual experiences, I have drawn from my clinical observation in classifying some components of all erotic relationships as being universal. Sexual desire, arousal, and orgasm are not exclusive to any group of people, and when two people hold one another as special and dear, it is nearly always called love.
A third challenge is culture as it relates to sexuality. In some areas, as with infertility, there exists a decent body of literature about the effect of culture on sexual beliefs or behaviors. In others, such as paraphilias, almost nothing has been written, although it can be assumed that an individual from a conservative family and culture may have different feelings about having a fetish than one from a more open and permissive culture. Fortunately, there exists online a tremendous resource, The Continuum Complete International Encyclopedia of Sexuality (Francoeur & Noonan, 2004), which any therapist can access to learn about the sexual practices of over 50 cultures.
Lastly, my hope is that the reader will find What Every Mental Health Professional Needs to Know About Sex to be a jumping off point for addressing the sexual concerns of clients and not the definitive or final word on how to do sex therapy. My own understanding of human sexuality continues to evolve, as does the field as experts research the multiple biopsychosocial factors that make us think and act as we do between the sheets. If I have done my job, your own interest in sexuality will be piqued and you will continue to deepen your knowledge and ability to be a therapist who “does sex.”
1 Sexuality and the Mental Health Profession
WhenI decided to become certified in sex therapy, my supervisor Stephen Braveman early on stated, “In our culture, no one escapes having some form of sexual damage.” Unfortunately, this statement also describes the influence of culture on mental health professionals across the lifespan. Consider how other systems, such as family, school, or peers, influenced your own sexual development. Perhaps you experienced being sexually harassed on the schoolyard or the workplace. You may be the one in four women or one in six men who were molested as children and who did not feel supported enough by parents or school to tell. You may have engaged in sex when you didn’t want to—or you even coerced someone into having sex with you—which changed your cognitive framework and your approach to sex, even in safe relationships. Or perhaps you were educated as a therapist in a setting influenced by the larger culture, where sexuality was a marginalized topic of study.
With any luck, you grew up to be a sexually functioning adult capable of emotional and physical intimacy with a partner of your choosing, but there is a strong likelihood that you have had struggles with your sexuality, as do surprisingly large numbers of men and women in the population at large (Laumann, Paik, & Rosen, 1999). It is in regard to our sexuality that we are perhaps most like our clients, kept in the dark about its nature
and discouraged from opening the door to understanding. Insight and knowledge into sexuality requires that therapists pay attention to their own development, but our training reflects the reluctance of our culture as a whole to “go there.” For most therapists, learning how to address sexual topics requires specialized training that may be difficult to access, requiring travel and other expense.
What happens to our clients if we, ourselves, don’t have or make the opportunity to understand our own sexuality? Can we call ourselves competent if we don’t assess or treat the entire spectrum of human experience, including those that are baffling or taboo? As self-appointed healers of mental health, I believe we must take responsibility to heal the whole person, including the sexual part of the self. Otherwise, we may inadvertently sustain or contribute to a client’s struggle with sexuality. Mental health and medical professions have yet to fully recognize that sexual problems can contribute to depression, anxiety, trauma, eating disorders, substance abuse, pain disorders, and so on; conversely, such problems can affect a person’s sexuality, yet remain unaddressed in the therapist’s office. Yet if we don’t “do sex” as part of our practice, we may miss out on an essential part of what is troubling our clients.
Consider Len, a client in his mid-60s who was so guilt ridden after his first attempt at intercourse that he struggled with erectile dysfunction for all the years that followed. Len became depressed after a divorce and sought relief through therapy, medications, and, at times, alcohol. In all his years of counseling, no one had asked him about his sex life—until he mentioned a urology appointment. Concerned he might be ill, the therapist asked more about the appointment. The question prompted Len to cry as he told her about his impotence. Fortunately, the therapist soon realized this was a long-standing, complex issue for Len and a referral was made for my help. After months of treatment with Len and his partner, he was, at last, able to resolve his sexual concerns.
But how different might Len’s life have been if someone had earlier inquired, “How’s your sex life?” Len’s treatment was influenced by a culture in which nonspecialized therapists lack training or comfort discussing sexual topics. He also needed a therapist who could use a systemic approach to understand why his struggle was so long-standing and intense, which had to do with his development in an extremely restrictive family, church, and community environment. The restrictive environment caused Len undue shame about his sexual needs, which in turn caused him to lose his erection in his first sexual encounter. Later in life, changes in Len’s biological system made attaining any kind of erection almost impossible, adding further frustration. Only when Len’s frustration was more painful than his secret could he break out of his shell and reach out for help.
Clients come to us to help them solve all kinds of problems, which may include sexual concerns. The Laumann survey (Laumann, Paik & Rosen, 1999) of male and female sexual problems—the largest of its kind—reported that about 60% of women and 30% of men have had some type of sexual dysfunction. With numbers like these, it is safe to assume that a good portion of your current clients have a sexual problem. If you do not ask, however, you may never hear about these issues. But clients sometimes do tell me, as an identified sex therapist, some of the reasons why they left a former therapist who didn’t talk about sex:
● One woman found the courage to seek help for the fact that she was still a virgin 7 years after her wedding night due to vaginismus (spasm of the vagina that prevents penetration), but she could not bring herself to tell the therapist about her problem. Since the therapist never asked about sex, the client got the message loud and clear: Sex is not spoken here.
● A couple trying to get past an affair that nearly destroyed their marriage couldn’t bring themselves to tell their “uptight” therapist that they had enjoyed swinging early in their relationship. The couple’s history added to their confusion about boundaries and rules in the marriage, but their weeks in therapy were useless because they feared the therapist would judge them if they disclosed their early history.
● Sam and Cynthia sought a therapist’s help for Cynthia, who believed she had a low sex drive as a result of being molested as a child. Because the couple had difficulty talking about sex, the therapist changed the topic from sex to finances because, explained Sam, “the therapist thought if we made more money, we’d be happier.” Two years later, Cynthia still had a low sex drive; fortunately, the couple sought appropriate help.
No one, least of all our clients, wants to be judged as defective, naive, or perverse. People want reassurance that they are essentially normal, or that they can become more what they think normal is for them. When therapists don’t talk about sex, they may convey a belief that the client is weird for wondering about their own sexuality. Of course, some therapists do ask about sex. In one survey, about half of therapists reported that they “always” ask about sex (Miller & Byers, 2009). But people in general (including therapists) over-report when it comes to sexuality, as they want to appear normal or current. What about the other half of therapists? There is an adage that we are always communicating, even if we say nothing. Therapists’ silence about sex in the therapy room sends many messages, but perhaps the loudest is please don’t talk about sex!
W hy the SI len C e about S exual I ty ?
Almost everyone is raised in an atmosphere of secrecy when it comes to emotional and psychological aspects of sex. The reasons are complex. Depending on one’s religious perspective, a person’s very conception can be shrouded with mystery. As we grow, we covertly observe romantic and sexual behaviors between adults of which we are told little. We experience our own biological urges, such as a desire to masturbate, but are given neither tacit nor explicit permission to ask questions. When we do ask, we may not get an answer—or we may get a lecture on why some sexual topic is naughty or dirty, something good girls and boys avoid. Although many of today’s parents talk openly with their children about sex, there are still households where sex is a forbidden topic. People still bar their children from attending formal sex education classes in school, and people from other countries, for example, Saudi Arabia, may not have been offered any sex education opportunities at all.
Our physical and psychological sexual development takes place on entirely different planes, and interactions between systems reflect this. Secondary sexual characteristics signal to adults around us that we must be protected from such risks as unwanted pregnancy or diease. Meanwhile, we are left to privately grapple with sexual dreams and fantasies, curiosity, and desire. Reflecting what is still often a Puritanical culture, we aren’t given information about giving and receiving sexual pleasure. The complexities of a sexual relationship are explained away with myths like, “All men are interested in is sex,” or “Once you get married, your sex life will disappear.”
We certainly aren’t told how to manage feelings of sexual inadequacy, so if a problem comes up like difficulty having an orgasm or getting an erection, we may keep it under wraps for decades. As a society, we also may act as if sexual problems appear suddenly in adulthood. However, as I have learned from my clients, teens (who on average in the United States begin having intercourse at 15) have sexual problems that plague them, sometimes leading to depression, eating disorders, alcoholism, and other mental illness. As therapists know all too well, secrecy and silence are associated with feelings of shame and guilt that can contribute to overall poor mental health. Nowhere, perhaps, is this truer than when it affects our sexual development.
It doesn’t help that sex does have a murky side. Subjects like sexual abuse, assault, and rape tend to be hushed by the victim and, if they learn about it, family members or friends. If the media gets hold of such a story, it is sensationalized, which may cause victims to further retreat, away from possible unwanted attention. Meanwhile, media attention on cases such as Jerry Sandusky, the Penn State football coach convicted of molesting children, do little to address underlying problems such as the need to educate children at an early age about appropriate physical boundaries, the right to say no to unwanted touch, and permission to tell if someone harms them.
Our culture also has done a poor job of acknowledging that pedophiles and people with other difficult sex and social problems do exist and frequently deserve compassionate treatment (Cantor, 2012).
For teens and young adults, date rape is distressingly common on college campuses; many young women have shared with me that the reputed response of campus security was so lukewarm that they made a decision not to report. Yet, its effects can linger well into adulthood. Today’s young adults are also the first to grow up in the digital age. Many have spent so much time viewing Internet pornography that they neglected to develop the social and sexual skills to have a real partner. How might things be different if they were raised in a culture that acknowledged sexual needs, made it easy to attain contraception, and talked openly about what it means to be in a healthy sexual relationship?
Therapists are not immune to such sexual negativity. Pope and FeldmanSummers (1992) report that about two-thirds of female and one-third of male therapists responding to a survey regarding sexual abuse among therapists had experienced molestation, the majority of incidents with a close relative. It isn’t difficult to surmise that one reason therapists may avoid the topic of sex may be that they have been victims of sexual abuse or exposed to other types of negative sexual experiences, from mild harassment to outright assault. Although therapists may be drawn to the field to help other victims become survivors, they may be disappointed with how little attention their graduate training gives to the sexual late effects of abuse.
The negative effects of such experiences may intensify what Saakvitne & Pearlman (1996) called vicarious traumatization. Vicarious traumatization is defined as “the therapist’s inner experience as a result of his or her empathic engagement with and responsibility for a traumatized client.” Listening to sexual material can be difficult for therapists if they have their own sexual struggles. Like our clients, we may have trouble setting appropriate sexual boundaries; struggle with questions about the morality of sexual practices (anything from casual “hook-ups” to looking at—or even engaging in the making of—hardcore pornography); be dealing with our own sexual inhibitions; be worrying about a partner’s sexual function after cancer or other illness; or simply have basic concerns about our own physical appearance and sexual attractiveness. Discussing such matters may create such distress for the therapist that they are simply avoided.
Another reason for many therapists’ silence about sex is the fear of becoming isolated or being ostracized by colleagues. Not only do therapists fear being judged by clients for expressing interest in their sex life, but also by other therapists who find dealing with sexual problems too uncomfortable or distasteful. For example, I recently lucked upon an opportunity to share space in a pretty office with a psychoanalyst. My deposit was promptly returned because, on reflection, the analyst decided that my sex therapy practice was not a good fit for her office, presumably since she and her clients
might happen upon my (drooling?) clients in the waiting room. Working with sexual problems can also feel unsafe in certain communities because of the social and political climate. Where I live in Southern California, condoms and lubricants are sold over the counter at the drugstore, but there are still parts of the country where such items are difficult to procure. Designating oneself as a sex therapist in such areas can mean opening one’s self up to ridicule or harassment.
Therapists may also be quiet about sex due to strict training in laws and ethics concerning sexual contact with clients, a topic covered in detail in Chapter 19. Therapists are rightly warned that because there is an inherent power differential in relationship with the client—who is dependent on us for emotional support—the potential for doing serious emotional damage by acting out sexual urges comes with enormous risk. Little is said, however, about reconciling the need to manage one’s sexual attraction or arousal while discussing sex in a therapeutic manner with the client. In any case, stern warnings about curbing one’s sexual feelings may send the message that it’s best not to deal with sex in the treatment room.
A final reason for therapist reticence about sex concerns diversity. While learning to tolerate cultural differences has been a priority in training programs, tolerance of a wide range of gender, orientation, and sexual behaviors has not. In my area of California, for example, human sexuality credits for marriage and family therapists have been cut to the minimum requirement in several schools. If therapists are to properly address client sexuality, then they must not only have appropriate training, but they also must become sexually sensitive—a tall order for those raised in an American society that lags in tolerance behind many developed countries, including neighboring Canada.
On the other hand, perhaps none of these concerns about being silent about sex applies to you! You might be a therapist like my intern Liz Dube, who, upon reading this chapter for a requested critique, quipped that the only thing that held her back from talking to clients about sex was lack of knowledge. Speaking for herself, she has had a long abiding passion to help people have satisfying sex lives. If that describes you, then you’re in luck, because this book will give you information that will help you fulfill a desire to help clients with their sexual struggles.
Otherwise, consider that you are about to become at least one step ahead of your clients as you learn more about sexuality. You won’t be a therapist who “doesn’t ‘do’ sex.” You will be able to help clients overcome their deepest fears so that they can enjoy one of life’s pleasures without undue shame or guilt. Increasing a client’s capacity to love and be loved often has a ripple effect in the client’s life, giving them the optimism, confidence, and freedom to tackle other developmental milestones such as finding a healthy relationship or even making a much-feared job change. Our sexuality is such a core part of who we are, and as therapists we are fortunate to be in a position to help our clients achieve health in this critical area of human existence.
