Sex Therapy with Erotically Marginalized Clients

Nine Principles of Clinical Support

Damon Constantinides, Shannon Sennott, Davis Chandler

• Publisher: Routledge
• Year: 2019
• eBook ISBN: 9781317205982
• Edition: 1
• Topic: Psychology
• Subtopic: Human Sexuality in Psychology
• Index: Psychology

Sex Therapy with Erotically Marginalized Clients: Nine Principles of Clinical Support provides a clinical guide to relational sex therapy with individuals, partnerships, polyships, and alternative family structures where one or more of the clients are erotically marginalized. This term refers to people who are at risk of being pathologized and oppressed both outside and inside the clinical setting due to their gender identities, sexual orientations, or sexual practices.

The book outlines nine principles for therapeutic practice which meet the needs of erotically marginalized clients, whose forms of sexuality and desire are rarely spoken about and for whom there is a dearth of language in therapeutic contexts. Each principle concludes with a series of 'key points' and then followed by illustrative clinical case studies, contributed by sex therapists and clinicians who self-identify as erotically marginalized and who also work with erotically marginalized clients. The book also provides a full glossary, 'Defining Erotically Marginalized Identities'.

The authors and case contributors use a radical and affirming lens to examine erotically marginalized identities that are often neglected. The book bridges gaps between the past, present, and future in the field of sex therapy and greatly expands the diversity of experiences and identities within the field, particularly the experience of multiple oppressions.

The book marks a valuable contribution not only to sex therapists but to the wider clinical and therapeutic community.

PART I

Foundations

Principle One

MAINTAIN TRANSPARENCY AND NAME SYSTEMIC AND INDIVIDUAL OPPRESSIONS

Introduction

We believe that sex therapists have the power to create radical spaces in which all people can work towards being free from oppression and are able to access their erotic selves. Power is inherent and implicit in the relation between therapist and client(s); the therapist has enormous power in the room. Attending to this dynamic and the ways in which the therapist can unknowingly recreate systematic oppression is a vital component of the relationship. Erotic marginalization is sometimes very clear, and sometimes very subtle. Different clients have different levels of awareness of how the experience of erotic marginalization is affecting them. Sex therapists have the potential, and responsibility, to see and name power dynamics related to erotic marginalization both inside and outside of the therapy room. How we do this is, as always, a complicated clinical decision based on the therapist and client(s).

Vignette

Raina, a 32-year-old mixed race Korean and white straight identified cisgender woman and her husband Sam, a 38-year-old white straight identified cisgender man have seen me for couple’s therapy for three years. They originally came to treatment because they wanted to responsibly and thoughtfully open their relationship. Sam has identified as polyamorous for many years and told Raina at the start of their relationship that he would want to open their relationship at some point, which she agreed to even though she has historically only been in monogamous relationships. They negotiated opening their relationship beautifully even though it felt complicated and fraught for both of them for a variety of reasons. Eleven months ago, they experienced a miscarriage and have been attending a bimonthly support group at a local health center and have felt incredibly supported by the other group members and the facilitator. After a year and a half of treatment they had dropped from weekly therapy down to every other week because they were feeling very positive about their connection with each other and with the folks they were choosing to date. After their miscarriage a year ago, they increased back up to every week until they found the support group. At that point they moved to every month therapy because Raina felt like she was “getting over therapized.” They called their monthly sessions “tune ups” and used the time to primarily discuss their relationship structure.

In a recent meeting following the support group, Raina and Sam came to a tune up session seeming obviously distressed. I checked in with them and asked what was happening. Raina quickly replied, “nothing, it’s not a big deal, I think I am just being too sensitive.” I pressed a bit and Sam chimed in, “Raina, can I share?” He launched into a story about the last group in which one of the newer members shared about friends of hers who had lost a pregnancy and subsequently decided to open their marriage. The member described their decision as “immature and irresponsible,” she felt like they just opened their relationship to escape the pain and sadness of losing a pregnancy. Raina and Sam had never shared their polyamorous identity with the group – primarily because it had never come up but also because they were nervous about the reactions of the group. “See?!” exclaimed Raina in session, “they think that polyamorous people are insatiable or avoiding their relationship, if they only knew how much work and conversation goes into our relationship!!”

I stopped the conversation and shared that I was feeling upset and very protective of them, that their invisible marginalized identity had been injured in what was supposed to be a space of healing. They initially both seemed surprised at how emphatically I was speaking, but they came to see that I was responding in a way that they both didn’t feel that they could in the moment because they are both the target of the oppression and also have a personal relationship with the group member who made the comments. We worked out how they could best support themselves and each other in this experience and possibly discuss what had happened with the group member. Raina decided that it felt best to her to bring it up in the next group without outing themselves as polyamorous. That way she could feel out their reactions to them talking about feeling upset that this person had judged another couple’s relationship decisions. We also explored how they both had to work to build up awareness of how they are oppressed so that they could ask for support around it.

In this example Raina and Sam experience erotic marginalization based on their relationship structure, an aspect of their relationship that was invisible to the other support group members. Naming and acknowledging this experience of oppression interrupts the process of internalization. Raina and Sam can see that their experience wasn’t about them, who they are, or their self-worth. Instead their feelings of frustration can be clarified as a reaction to the enactment of someone else’s prejudice. We hope that these nine principles provide guidance for sex therapists to see and support clients like Raina and Sam. Principle One starts us off with establishing a social justice foundation for our clinical sex therapy work.

Foundations

Principle One is built on the foundations of social justice, the Freedom Paradigm, and Preemptive Radical Inclusion. These three concepts interconnect to form a grounded beginning from which we can practice sex therapy with erotically marginalized clients.

Social Justice

Social justice is at the root of all of the sex therapy we do within and outside of the therapy office. We bring a social justice perspective in our sex therapy from the field of Social Work. The National Association of Social Workers (NASW) Code of Ethics (The National Association of Social Workers, 2017) lists the second ethical value as Social Justice, with the ethical principle as “Social workers challenge social injustice.” It goes on to say that “social workers pursue social change, particularly with and on behalf of vulnerable and oppressed individuals and groups of people.” For us, social justice is the bedrock on which our sex therapy work is built.

Raina and Sam experienced marginalization in their support group based on their polyamorous relationship structure. In this case, as with many examples of erotic marginalization, we lack a coherent language to describe the experience of this kind of oppression. When clients don’t have the words that they need it can be difficult for them to name their experience and identify their feelings. In this example the clinician named a possible experience and allowed the couple to decide how well that fit and how they wanted to move forward. A sex therapist might also be interested in how this experience of marginalization affects both Raina’s and Sam’s sexual experience as a couple and with other partners.

Freedom Paradigm

The Freedom Paradigm, conceptualized by Fred J. Hanna and Betty Cardona (2013), provides a way for us to re-envision our sex therapy work with erotically marginalized clients by framing the therapy goal in a strengths-based and holistic way. Hanna and Cardona proposed that, “the purpose of virtually all counseling endeavors, at some level and to some degree, is to set people free” (363). Hanna and Cardona’s concept of freedom in regards to counseling is described as, “a psychological state wherein a person is not bound by psychological inhibitions or restrictions, including symptoms such as anxiety, depression, emotional pain, obsessive thoughts, or compulsions” (365). The application of the Freedom Paradigm to sex therapy allows for a deeper understanding of sexual desire and sexual contentment. Sexual desire and behavior is often seen as an individual experience, and therefore when clients experience problems with their sexual desire or behavior, it is often experienced as a personal failing or fault. The Freedom Paradigm’s emphasis as psychological symptoms being caused by the lack of the experience of true freedom (including freedom from oppression) broadens this picture to include external experiences that clients internalize. Our culture sends many explicit and implicit messages about sex and sexuality that are both controlling and damaging. These messages include what your body should look like, how much sex you should have, how you should have it, how long it should take you, who you should have it with, and what it should mean to you (to name a few). When clients show up in our office seeking help for a sexual issue, they carry in all of these internalized messages. And these messages get in the way of experiencing and understanding their sexualities.

Preemptive Radical Inclusion

What if we always assumed that the person we just met was someone who was experiencing oppression and marginalization? Cindy Beal developed a framework, Preemptive Radical Inclusion (PRI) (Beal, 2018), that moves us toward creating a space that is truly inclusive. When we practice PRI in our work, we are intentionally making an assumption that we are sitting with someone who experiences marginalization, whether we can see it or not. This practice allows us to notice and name our own privileges and to be aware of how they are showing up in our clinical work. It is a way of decentering our own experiences in order to make space for our clients.

Practicing PRI means that we are not assuming a client’s gender identity, sexual orientation, sexual identity, race, ethnicity, religion, or any other part of their experience. It means specifying that you’re talking about a cisgender man instead of just using “man” and “transgender man.” Or clarifying client’s relationship structures and being curious about the language that they use and what it means to them (Can you tell me what marriage means to the two of you?). By practicing PRI in our sex therapy office and in our lives we are making space not only for people’s whole lived experience, but a space in which no part of themselves needs to be left behind. Cindy Beal states, “Preemptive Radical Inclusion lives at the intersection of trauma-aware and anti-oppression practices.” The stance of PRI is critical to working ethically with erotically marginalized clients because the clinician does not wait for a client to bring a need and then meet the need, instead, the clinician creates a therapeutic environment that preemptively supports a client’s multiple intersecting erotically marginalized identities.

Systemic and Individual Oppression

It is typical for sex therapists to receive training to work with specific populations. For example, transgender clients, kinky clients, polyamorous clients, and lesbian, gay, and bisexual clients (LGB) all have specific concerns and experiences that an untrained clinician needs to learn about. And, one thing that they all have in common, is the experience of oppression. The development of the term “erotically marginalized” came from conversations that we had together about the sex therapy work we were doing. Erotically marginalized clients all experience oppression in some way that is related to their sexual self. The field of sex therapy is built on behavioral research that focused on cisgender and heterosexual people and their individual experiences that is not always pertinent or appropriate for erotically marginalized clients.

Oppression and Sexuality

The experience of oppression is, “prejudice and discrimination as a result of being a member of a group that has historically been marginalized (e.g., women, people of color, immigrants, or LGBTQQ individuals)” (Singh & Harper, 2012, p. 284). The history of the field of sexuality is full of experiences of sexual oppression from Kraft-Ebbing who in 1886 believed that sexual desire was only for procreation and all other sexual behavior was deviant (Bullough, 1995; Califia, 2003) to Magnus Hirschfeld whose Institute for Sexual Research was destroyed by the Nazis in 1933 (Stryker, 2008). Sexologists have historically been both the oppressor and the oppressed and that is also true in our current practice of sex therapy; privilege and oppression “operate together as two sides of the same coin” (Singh & Harper, 2012, p. 285). Sex therapists who have an awareness and understand of their own identities including their experiences or privilege or oppression are more able to constructively address privilege and oppression in the therapy room (Singh & Salazar, 2010).

Intersectionality, Intersecting Oppressions

The roots of what is today described as intersectionality come from the work of black and brown women. The Combahee River Collective, a Black lesbian feminist organization, created a statement in response to the multiple positions of marginalization within the white feminist movement of the 1970s (Combahee River Collective, 1977). The statement they released was revolutionary and in it they developed the concept of “identity politics.” Before intersectionality was a recognized term, they argued for an intersectional approach to working towards justice and liberation. They believed that “the liberation of all oppressed peoples necessitates the destruction of the political-economic systems of capitalism and imperialism as well as patriarchy” (Combahee River Collective, 1977). Additionally, they asserted that “if Black women were free, it would mean that everyone else would have to be free since our freedom would necessitate the destruction of all the systems of oppression.” Their statement reveals that all systems of oppression are interwoven and inextricably linked, in order for any true liberation to occur, everyone must be set free.

Kimberle Crenshaw (1989) popularized the term intersectionality in her article Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Theory and Antiracist Politics. She explores the experience of Black women as a way of emphasizing the importance of an intersectional frame, showing that examining race or gender in isolation would not adequately account for a Black woman’s lived experience. She argues that “Black women are sometimes excluded from feminist theory and antiracist policy discourse because both are predicated on a discrete set of experiences that does not accurately reflect the interaction of race and gender” (140). Intersectionality holds that while individuals are marginalized or oppressed based on specific group membership, every person is a member of many groups, both privileged and marginalized, and all of these identities and experiences work simultaneously and inextricably.

As anti-racist and transfeminist clinicians, we believe that work with marginalized clients needs to include an understanding of the ways in which intersecting oppressions operate. This is both foundational to our therapeutic frame and to our clinical work. The systemic piece, that “Intersectional paradigms remind us that oppression cannot be reduced to one fundamental type, and that oppressions work together in producing injustice” (Collins, p. 21) fuels our commitment to help marginalized clients experience freedom from oppression both as therapists and outside of the office. We also believe that is in the responsibility of sex therapists to have an awareness of the ways that they experience marginalization and the ways that they have access to privilege in order to minimize reenacting systems of oppression in the therapeutic relationship.

Microaggressions

In practice, microaggressions describe the small ...

Table of contents

• Cover Page
• Half Title
• Praise
• Title Page
• Copyright Page
• Table of Contents
• List of Figures and Tables
• Author Biographies
• Contributor Biographies
• Preface
• Acknowledgments
• Introduction
• Part I Foundations
• Part II Practice
• Part III Systemic
• Glossary: “Defining Erotically Marginalized Identities” by Ellie K. Lipton
• Appendices A–D: “Referral Letter,” “Self-Determined Gender Psychosocial Form,” “The Allyship Practice Model for the Transfeminist Therapeutic Approach,” “Professional Ethics Statement”
• Index