The Wiley Handbook of Sex Therapy

Zoë D. Peterson, Zoë D. Peterson

• Publisher: Wiley-Blackwell
• Year: 2017
• ISBN:
  9781118510414
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

The Wiley Handbook of Sex Therapy is a comprehensive and empirically-based review of the latest theory and practice in the psychotherapeutic treatment of sexual problems across client populations.

• Structured in four sections covering specific sexual dysfunctions, theoretical approaches to sex therapy; working with client diversity; and future directions in sex therapy
• Advocates a holistic approach to sex therapy with a focus on using a range of psychotherapeutic theories and techniques rather than only the most popular behavioral strategies
• Includes case studies which highlight the broad spectrum of diverse conditions that clients can experience and which sex therapists can therefore encounter in the consulting room
• Includes contributions by more than 60 experts from a wide range of disciplines

1
Introduction

Zoë D. Peterson

What is Sex Therapy?

Sex therapists will tell you that one of the fundamental uncertainties that often drives clients into sex therapy is the worry: “Am I normal sexually?” I, in turn, often wonder: “Am I a normal sex therapist?” In my own work as a therapist treating sexual concerns, I sometimes use traditional sex therapy techniques such as sensate focus, but I also rely heavily on my broader training as a clinical psychologist and on my overarching feminist and constructivist psychotherapeutic theoretical orientation. Am I still doing sex therapy if I am not explicitly discussing the sexual response cycle, assigning sex‐related behavioral homework, or helping my clients to discuss pharmaceutical treatment options with their doctors?

Thus, one of the most challenging aspects of editing this volume was determining what counts as sex therapy. As I set out to choose chapter authors and select the topics that would be addressed, I was forced to consider my own insufficiently‐articulated viewpoints regarding questions such as, “Where does sex therapy stop and general psychotherapy begin?” and “What are the qualifications for a ‘sex therapist’?”

I am certainly not the first to raise these questions about the definition of sex therapy. Tiefer (2012) pointed out that—broadly speaking—across time, sex therapies have included ancient love potions, bloodletting, Masters and Johnson behavioral techniques, Viagra, and YouTube kissing advice videos, among others (p. 312). Yet, she acknowledged that, in contrast to this broad expanse of sex therapies, the term “sex therapy” has become nearly synonymous with a dysfunction‐focused behavioral or pharmaceutical treatment approach.

Similarly, Levine (2009) reported that he now rejects his former identity as a “sex therapist” because, to him, sex therapy is too narrow and simplistic. He argued that sex therapy has become tantamount to treating DSM‐defined sexual dysfunctions with an overly simplistic, behavioral‐technique‐focused approach. He contended that sexual problems are far too broad and complicated to be explained and treated using a single theory or treatment approach.

Binik and Meana (2009) agreed that the term sex therapy originally referred to the techniques championed by Masters and Johnson (1970)—psychoeducation about sexual functioning, behavioral homework, and so on—but they maintained that, over time, sex therapists began to use the same techniques and theoretical orientations that were used to treat other psychological problems. The authors argued that “sex therapy” is just therapy. Given (1) the lack of clear distinction between sex therapy, as it is typically practiced, and general psychotherapy; (2) the lack of a unifying theory of sex therapy; and (3) the lack of regulation regarding who may call themselves a “sex therapist,” Binik and Meana (2009) proposed that the treatment of sexual problems should be integrated into general psychotherapy practice rather than being treated as a separate subspecialty.

What Problems do Sex Therapists Treat?

Indeed, there is perhaps an even more basic question that must be answered before we can define sex therapy, and that is, “What is a sexual problem?” The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM‐5; American Psychiatric Association, 2013) codifies the sexual difficulties that are officially acknowledged by the field of psychiatry. The DSM sexual dysfunction diagnoses are exclusively focused on sexual performance: desire, arousal, orgasm, and pain‐free intercourse. This focus on genital performance in the DSM‐5 and in earlier versions of the manual has been heavily critiqued for being heterosexist and phallocentric; for promoting an anxiety‐provoking, performance‐oriented approach to sex; for ignoring cultural differences and gender‐based power differences; and for sidelining essential facets of sexuality such as relationships, emotions, and pleasure (e.g., Apfelbaum, 2012; Kleinplatz, 2012; Tiefer, 2001).

Despite these cogent critiques, there is no denying that, for clients, it is often the symptoms of DSM sexual dysfunctions (e.g., lower levels of desire than they wish, erectile difficulties, orgasmic difficulties) that drive them into sex therapy. Of course, this raises a chicken‐and‐egg conundrum: Did these issues become the focus of the DSM diagnoses because they were the most troubling sexual issues for clients, or are clients most troubled by these sets of symptoms because they have been conceptualized and labeled as dysfunctional by the medical establishment and, in turn, by popular culture? In either case, clients do present with these difficulties, and as sex therapists, we frequently must address them in some manner. Depending on the sex therapist’s viewpoint, this might involve suggesting medications or behavioral exercises with the goal of relieving symptoms; it might involve helping the client to re‐think the assumption that firm erections and timely orgasms are the only path to sexual pleasure and connection; it might involve addressing the underlying psychological and relational distress that is seen as leading to the sexual symptoms; or it might involve some combination of all three of these. Thus, although some sex therapists reject the performance‐oriented, genital‐focused nature of the DSM sexual dysfunction diagnoses, all sex therapists will be forced to confront these in the therapy office.

There is no question, however, that the DSM sexual dysfunctions do not capture the full range or complexity of the sexual concerns that propel our clients to seek therapy. Levine (2010) categorized sexual difficulties as disorders (those identified by the DSM), problems (frequent sources of suffering that are not captured by the DSM disorders), and worries (concerns about sexual issues that detract from sexual pleasure). In many cases, problems (e.g., anger and resentment about a partner’s infidelity, discomfort with or shame about sexual attractions) and worries (e.g., concerns about body image, fears that one is not sexually pleasing a partner) may actually be more distressing and have a more pervasive negative impact on sexual pleasure and enjoyment than relatively more straightforward disorders of physiological function. It is very often these problems and worries—rather than diagnosable disorders—that motivate clients to come to see a sex therapist.

What Techniques do Sex Therapists Use?

As noted by Kleinplatz (1996), Masters and Johnson’s behavioral techniques have become synonymous with sex therapy; as she put it, these techniques are “the Kleenex” of sex therapy (p. 190). This tendency to equate sex therapy with symptom‐focused behavioral interventions—such as sensate focus and the squeeze technique—obscures the fact that there are actually many different brands of sex therapy. In reality, sex therapists, like all psychotherapists, employ a variety of therapeutic techniques and are guided by a variety of theoretical orientations when they work with clients to address sexual problems. Despite this fact, with a very few notable exceptions (e.g., Hall, 2012; Hertlein, Weeks, & Gambescia, 2009), little is written about theoretical approaches to sex therapy.

Many sex therapists advocate for a biopsychosocial approach to sex therapy. This approach recognizes the importance of integrating medical, psychological, and relational components of treatment. Despite the importance of an integrated approach to treatment, however, the label “biopsychosocial” is uninformative in revealing the theoretical assumptions that guide the psychological and relational work that occurs in psychotherapy. Thus, a therapist working from a “biopsychosocial approach” might treat the psychosocial aspects of the problems using behavioral, cognitive, systemic, narrative, or emotion‐focused interventions.

What Should Sex Therapy Be?

I agree with Tiefer (2012) that “sex therapy is politics” (p. 31). For that matter, all therapy is politics, but this is especially apparent in the case of sex therapy because issues of sexuality and sexual behavior are so highly politically contested. Thus, how “expert” professionals define “a sexual problem” and “sex therapy” speaks to their values—and helps to shape the values of the broader culture—around what is and is not sexually “healthy” or “normal” and which treatments are legitimate for addressing sexual concerns. Given that, in this volume, I wanted to represent a diversity of individual values and politics related to what counts as “a sexual problem” and as “sex therapy”.

However, to acknowledge my own values and politics, I also wanted to adopt an expansive definition of sex therapy as any therapy that values and promotes enjoyable sexuality as an integral part of overall physical and mental health. Levine (2009), in describing his rejection of the “sex therapist” label, said:

Sex therapy has no relevance to the management of gender identity disorders, sex perpetrators, paraphilics, the sexually compulsive, sexual victims, sexual risk taking, nonsexual relationship conflict, the anxieties of sexual beginners, and so on, unless, of course, by sex therapy we mean all things involving any aspect of sexuality brought to our clinical attention. (p. 1033)

I hope that the version of sex therapy advocated in this volume does, in fact, have relevance to all of those important sexual issues noted by Levine. Of co...