New Directions in Sex Therapy

Innovations and Alternatives

Peggy J. Kleinplatz, Peggy J. Kleinplatz

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136333323
• Edition: 2
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Winner of the 2013 AASECT Professional Book Award!

New Directions in Sex Therapy: Innovations and Alternatives focuses on cutting-edge, therapy paradigms as alternatives to conventional clinical strategies. With each passing year, the treatment of sexual problems seems to emphasize more medical and pharmacological interventions. There is correspondingly less interest in the experiences of the individuals or couples involved. This book expands the definition of our field.

Part I highlights the major problems and criticisms facing sex therapy and furnishes a rationale for new directions. Included in this new edition are critiques of "sexual addiction" nomenclature, the neglect of the ethical dimension in sex therapy, and there is a call to expand our vision of what sex therapy can attain. Part II demonstrates new approaches to dealing with traditional sex therapy concerns, including lack of desire and erectile dysfunction as well as innovative goals, such as integrating sexual medicine with sex therapy, using client feedback to customize therapy for the particular individual/couple's best interests, promoting relationship growth in working with transgender clients, and transcending sexual function/dysfunction to optimize erotic intimacy in long-term couples. This 2nd edition of New Directions in Sex Therapy: Innovations and Alternatives is replete with helpful new clinical illustrations across the spectrum of theoretical orientations (e.g., systemic, narrative, Experiential, CBT) to demonstrate these approaches in action.

This book is intended for anyone who deals with sexual issues and concerns in therapy–clinicians of every kind, novices and advanced practitioners–rather than only those who define themselves as sex therapists.

Part I

Critiques of Conventional Models of Sex Therapy

A Preview of the Critiques and Their Implications

Why exactly do we need a new direction in sex therapy? In Chapter 1, Bernard Apfelbaum, Ph.D., takes on this question and offers us his answers. He has an impressive ability to make sex therapists take a fresh and closer look at what we thought we already knew. In Chapter 1, he has us consider the “hidden curriculum” that governs the subtlest and crudest of our interactions during sex. The social mindset that rules our expectations of ourselves and our partners has been obscured, rather than challenged, in much of what Apfelbaum sees in contemporary treatment of sexual problems. The continuing paradigm of “sex as functioning” eclipses the extent to which our ideals of normalcy actually impede sexual intimacy. If anything, they are likely to create a great deal of loneliness during sex. He suggests that the ground for real erotic connection may lie in speaking the unspeakable during sex. Imagine being able to say whatever you are feeling during sex, even when that includes anxieties, insecurities, and resentments. Although Apfelbaum focuses on the contributions of the early pioneers in sex therapy, it is his own unique insights and subtle distinctions that merit considerable attention. Apfelbaum may be too humble to take credit for his own innovative perspective.

Perhaps the most powerful and persistent criticisms of conventional sex therapy come from feminist theorists and clinicians. For over 30 years, Leonore Tiefer, Ph.D., has provided an extraordinarily articulate and incisive voice in the feminist discourse in sexology. In Chapter 2, Tiefer offers a brief history of feminist perspectives on sex therapy—not necessarily originating from within the field—and the various ways these criticisms had been ignored and circumvented within mainstream sex therapy. She chronicles the need for alternative voices and the emergence of the New View movement in 1999. The New View group developed an alternative diagnostic nosology of sexual difficulties based in etiology. The purpose was to situate sexual problems in the context in which they arise as opposed to essentialist and reductionistic understandings of sexual dysfunctions and disorders. Once this grassroots campaign began to spread, its members confronted and opposed new attempts at the medicalization of sexuality, including female cosmetic genital surgeries and attempts to secure FDA approval of drugs to treat the increasingly amorphous “FSD” (female sexual dysfunction). Tiefer discusses the role of activism in sexology and in guiding the field toward models based in “emancipatory sexual values and politics.” Her work is oriented toward making the world a safer place for sexual pleasure.

If the feminist literature has been helpful in focusing attention on the social construction of female sexuality, the new psychology of men has applied this perspective to the understanding of male sexuality in all its complexity. In Chapter 3, Gary R. Brooks, Ph.D., and William B. Elder, M.S., have used this lens to examine some of the areas in which dominant discourses of male sexuality have been oversimplified. These areas include “sex addiction”, binge drinking, and other kinds of apparently self-destructive behavior, sexual and otherwise. Although neither Brooks nor Elder identifies as a sex therapist, they point out that any therapist dealing with men needs to be aware of the myriad manifestations of the traditional male gender role script and their limiting effects on male development. A nuanced appreciation of men’s intimacy needs and the social barriers to full, male sexual expression must be incorporated into our understanding of men’s behavior in relationships. They suggest that the socialization process in which men’s emotions are cut off from their sexuality creates non-relational sexuality among men. The solution—to promote sexual integrity/integration—is obscured when we focus on only the symptoms of sexual dysfunction or on public misbehavior. They argue that we must foster cultural change; furthermore, sex therapy must include ways to help men become aware of and respond to their needs for intimacy.

Some of the major questions with regard to human sexuality have rarely been asked, let alone answered. Just one of these questions posed in Chapter 4 concerns the nature of distress or suffering in the realm of sexuality. What is it, exactly, that we are trying to heal? From what vantage points have we attempted to grapple with this issue? In this chapter, Christopher M. Aanstoos, Ph.D., suggests that we may require another perspective if we are to gain a deeper understanding of our clients’ sexual disappointments, hopes, and dreams. Aanstoos argues that the reductionistic, objectifying approaches to sexuality currently prevalent in our field have failed to illuminate the uniquely human dimension of lived sexual experience. Sexual science has often situated the body as the unit of study with little emphasis on embodied sexuality. It is as though subjective meaning and context have been extricated from our analysis. He invites us to let go of our abstractions and reminds us of the primal nature of human touch and of the immediacy of erotic encounter. He presents us with a phenomenological model of human sexuality. The implication for clinicians is that we may want to try to heal the diminished capacity for erotic openness, mutual resonance, and the ability to be present to/with our partners. His way of thinking about and discussing sexuality is more reminiscent of the perspectives of poets, musicians, and choreographers than it is of sex therapists and is inconsistent with most of our work. We may wish to consider changing that.

One premise implicit in the existence of therapy for sexual problems is the idea that we have some notion of what is problematic and what is not. Certainly, our treatment paradigms and our classification of sexual disorders imply a solid conception of normal versus abnormal sexuality. In Chapter 5, Paul Joannides, Psy.D. takes us through a particularly vexing problem and wonders aloud if we have any foundation for understanding the phenomenon in question. Whether it is called “sexual addiction”, “hypersexuality”, or “compulsive sexuality”, it is increasingly prevalent in the media and in our offices. However, as clinicians, we cannot even agree on a name for it. Each term brings along its own conceptual baggage, including an underlying conception of the problem, its causes, treatments, mode of evaluation, goals, and even whether or not it actually constitutes a problem. Joannides examines the history of the construct and whether this disorder even constitutes a unitary, discrete, and distinct clinical entity. The fact that our conceptions of it have varied so widely over time and depending on whether the “patient” was male or female, married or single suggests that it reflects moral judgments more than pathology. No one disputes that there are individuals who are out of control of their sexual behavior and that some of them may seek help; at other times, it is their families or employers who want us to fix them, whether or not they agree. The question is, how do we make sense of such behavior? When is the behavior pathological and when is it merely the symptom of an underlying problem? And who is assigned to ascertain how much is too much when there is disagreement as to objective criteria for diagnosis? Joannides illuminates the complexity of examining sexual behavior when sexuality per se evokes such a strong, unacknowledged overlay of moral judgments against a clinical backdrop that is allegedly value-free.

It seems rather curious that ethics should be overlooked in the training of sex therapists. Of course, we do have professional codes of ethics, either from our home disciplines (e.g., psychology, social work, medicine) and licensing boards or from professional certifying bodies (e.g., the American Association of Sexuality Educators, Counselors and Therapists). Sex therapists are expected to adhere to the relevant regulations as part of the requirements of licensure. However, the historical emphasis on courage, honesty, fairness, and compassion has increasingly been left out of clinical training. The character or values orientation in the realm of ethics has been lost in the emphasis on empirically supported treatments and “best practices”. In Chapter 6, Daniel N. Watter, Ed.D. shows that this approach leads to questions such as, “What is the best treatment for this problem?” rather than “What changes would be in the best interests of this client/couple?”

If this is unfortunate for health care providers in general, it is especially grievous in the development of sex therapists. Dealing with sexuality entails attending to one of the most salient and significant aspects of behavior, emotions, beliefs, and identity itself. Values are a crucial aspect of one’s sense of self as a sexual being. Sex therapists are trained to be objective, though there is no way of keeping our clients’ values out of the consulting room. How are we to deal with value differences between the two clients in our offices? How are we to deal with the complexities of differences in clients’ values around sexual desire discrepancies, unusual sexual proclivities, negotiating extramarital sex/polyamory, Internet sex, and so on? Our theoretical orientations are surely of some utility here, but we are being disingenuous if we deny the ethical aspects of our clinical interventions. Beyond “no sleeping with clients,” what values are to guide us when sexual attraction enters the patient-therapist relationship? Watter reminds us of the moral dimension of clinical decision-making in sex therapy and inspires us to uphold our professional and personal integrity.

The most fundamental aspect of all therapy is almost certainly its goals. Its methods, moment-by-moment interventions, and objectives as well as its criteria for effective outcome are predicated on its ultimate aims. In Chapter 7, I will take issue with how little sex therapy seeks to achieve. It will be argued that the parameters of what can be accomplished in sex therapy are already circumscribed for the individual or couple before even entering the therapist’s office. The limits of our work will be linked to our underlying values and vision of sexuality; our willingness to settle for reversal or control of problematic sexual symptoms rather than aiming for profound change, generated from within; our focus on treating one client at a time rather than intensive social advocacy to prevent problems; and our reluctance to embrace sexual diversity. In the years since the first edition of this book, my research team and I have sought an alternate set of goals by studying those who have experienced optimal sexuality over the course of a lifetime. They have led us to re-vision sexuality, to embrace embodiment, authenticity, transparency, vulnerability and extraordinary levels of communication, interpersonal risk taking, and the possibility of transformation. The implications of these findings for changing the goals for clinical practice will be suggested.

1

On the Need for a New Direction in Sex Therapy

BERNARD APFELBAUM, Ph.D.

It is becoming apparent that an overall new direction is needed, both for sex therapy and for the study of sex itself. The focus on functioning has always dominated both the field and the larger culture. In what amounts to a black-box conception, what goes on between partners in bed is treated as no more than an outcome of what they bring to it, so there has not been much reason to pay attention to the sexual moment. Consequently, when we describe a couple as making love, we say more than we realize.

How Love Is Made

Given all the problems that can spring up when two people try to do anything together, and all the familiar issues that plague relationships, how do we manage to create a harmonious, even blissful, erotic experience? We do it by developing or capitalizing on an upbeat mood, spontaneously bypassing, that is, blocking out complaints and frustrations and focusing on the most favorable image of our partner, or of some other real or imagined partner. Lovers feel impelled to engage in mutual appreciation; seduction begins with a compliment. This requires concentration, holding a steady mental set, and being relatively independent of one’s partner, although the resulting experience can be one of ultimate closeness, a dissolving of ego boundaries.

We sense that the erotic mood is responsive to the experience of unconditional acceptance, and we are driven to create it. When we succeed, we do not marvel at the accomplishment. Instead, we think that all we needed to do is to get out of the way, to clear our minds, and to let go. In our erotic reveries, we experience sex as a surge that takes us over without effort, and that is our reference model. This is the two-minds-with-a-single-thought experience we try to re-create in sex with a partner. Yet it is that same partner whose presence can interfere with the experience.

Bypassing can be entirely deliberate, as when holding an imagined partner in mind, but more often it is automatic, aided by each partner’s effort to be a good sex object. This creates a tension between the erotic image of the partner and other feelings about him or her that come up spontaneously or in reaction to some off-note. Here are two people, each holding on to what may be a coinciding or widely divergent experience of the relationship at any given moment.

Although all of this is entirely familiar, where is it in the vast literature of sex? No one would deny that partners are engaged in a moment-by-moment relationship, and no one believes that what happens is simply reflexive. Right at this point there is a gap in our thinking. It is jarring to think of partner sex as a complex and difficult social situation, because it even is thought to be free of social constraints, an opportunity to be our authentic selves.

Once foreplay begins, we move cautiously, even in slow motion, avoiding eye contact; being mostly silent (except for “sex talk”) or speaking in hushed tones, in low light, acting as if everything is okay; avoiding any awkwardness, even pauses, let alone interruptions, stoically enduring discomfort. When passion does take over, we do not celebrate it as the outcome of our conformity to these rather unforgiving conditions.

Acting this way is strongly remini...