Chapter 1. A Professional View of Sexual Life

Despite the numerous sexual images in modern culture, public references to sex and scandals, and commercial panaceas, the first important characteristic of any individual’s sexuality is that it is private. Individuals guard their sexual lives with several distinct protective layers. We do not reveal everything to our partners. Partners keep their shared sexual behaviors to themselves. Individuals may not clearly tell themselves of their own desires. Children and adolescents keep their sexual thoughts and behaviors from their parents. It is our professional privilege that patients are willing to share aspects of their privacy so that we can help them. Session by session they reveal what they consider to be relevant to their problem. Privacy is so formidable a force, however, that it is not realistic for us to expect that patients will ever reveal the entirety of their sexual lives to us. We are always working with limited information. Please do not be insulted; we aim for sufficient, not complete, knowledge.

An individual’s sexuality involves both eroticism—the subjective experience of fantasy, desire, attraction, and preoccupation—and sexual behaviors. Professionally, we distinguish between eroticism and solo and partnered sexual behaviors, even though some of our colleagues and patients use these words as synonyms. Privacy envelops patients’ eroticism and the identity of some of their past and present partners, and what behaviors they have engaged in. As a result of this natural guardedness, we content ourselves with what has been revealed and do not push patients beyond their comfort level. More details may or may not be forthcoming in future sessions.

Certain professional characteristics make it easier for patients to reveal their eroticism and sexual behaviors. Our interest, calm manner, knowledge of the problem, clarifying questions, and nonjudgmental attitude increase their confidence that it is safe to provide details to us. However, to the extent that we demonstrate the opposite traits—apparent anxiety, indifference, irrelevant questions, lack of information, and censoring responses—our chances for therapeutic success diminish. These positive professional characteristics are not different from the features required to deal skillfully with other mental health challenges. They are just more difficult to attain for young mental health professionals. There are several important reasons for this.

All of us have socially learned that eroticism and sexual behavior are matters so private that we should not ask such questions of a friend, relative, or acquaintance. We learn to talk around the subject unless the information is voluntarily shared. It is important to realize that our license—our culturally prescribed role as a therapist—enables us to be curious about this topic. Nonetheless, the layperson in a new professional role naturally avoids the subject and, when first confronted with a patient’s sexual concern, may experience unease. Without in-depth discussions in seminars or in supervision, many young professionals will unfortunately avoid directly discussing sexual matters for the rest of their professional lives. They will use some justification, such as “Sexual problems are the result of other issues that I do focus on.” The results are likely to be a failure to get to the heart of the patient’s sexual experience and the attainment of a glancing view of their patients’ sexuality. My colleagues and I have benefited from uncomfortable therapists in our community who do not feel equipped to respond to their patients’ sexual concerns. They refer these patients to us. Sexual problems are too prevalent for this to be a good idea. The purpose of this book is to prevent professional avoidance of sexual concerns and to encourage therapists to try to personally be of assistance.

There is another reason why sexual topics create so much clinical discomfort. Each of us has a strong natural interest in the topic of sex, yet professionals sidestep the subject. Why? One way to find the answer is to consider the impact of movies on our subjective experiences. Scenes that are romantic, that suggest the imminence of lovemaking, or that explicitly display adults enjoying sex routinely sexually excite viewers. Our limbic systems respond with arousal when imagining or watching others behave sexually. This may occur even if we disapprove of what we are seeing. This voyeuristic response extends to reading about sex and listening to accounts of sexual behavior. Being slightly aroused, even transiently, in the context of clinical activities seems dangerous to many. Some clinicians think it forbidden. For instance, hearing about a patient’s pleasures in oral-genital sex may immediately be arousing or take the professional to his or her own experiences. This may create arousal, disgust, or envy. We are human. What we listen to, we subjectively respond to. When we consider our private response to be unprofessional, we will find a way to avoid repeating the experience in the future.

What is forbidden, what is clearly unethical, are the behaviors that constitute the slippery slope to violation—the flirtations, compliments, and personal revelations. These behaviors typically precede sexual behavior with the patient. Sex with a patient is defined as the use of the patient’s body for the professional’s pleasure or the use of the patient’s mind for the clinician’s arousal. Thus, sex can occur without intercourse and can include sharing erotic fantasies about each other. We are not going to confuse such professional sexual boundary violations, however, with our private transient experiences of arousal and our private personal comparisons with what the patients are reporting. Violation of the sanctity of the professional relationship is light-years away from these ordinary momentary subjective experiences when trying to improve a patient’s sexual life. The confusion of these two phenomena creates the obstacle to future effective clinical work with sexual problems.

Much of conscious life about sexuality does not involve behavior. It involves fleeting thoughts and brief waves of feeling. These subjective erotic processes are far more common in adolescence and young adulthood but are part of most people’s lives throughout the life cycle, particularly when individuals are physically well and not overwhelmed by some dilemma. When sharing eroticism, patients can only make general summary statements about what is or what is not occurring in their minds about themselves and others. The inherent limitations in the accuracy of patient summaries of their erotic experiences derive from how difficult it is to be a reliable narrator of this mental arena. Their need for privacy, embarrassment, fear of your disapproval, and unexpected spontaneous mental events contribute to this. We have discovered, for instance, that many women who sought help for low or absent sexual desire had some manifestations of sexual desire. It may have been that their summary was correct about the paucity of their desire, or that desire reappeared during our work together in research or in therapy, or that they understood desire to be for their partner rather than for anyone in particular. We have also learned that men may complain of erectile problems when, in fact, they have rapid uncontrollable ejaculation, or complain that they have premature ejaculation when, in fact, they have erectile dysfunction, or both. We need to accept that patients tell us what they are able to share, and it is our responsibility to clarify their complaint more accurately.

The work that we are undertaking to better understand how to assist patients in this arena of life has its roots in the earliest of medical writings.¹ In every era, professional writings begin with classification, move on to theories of causation, and end with therapeutic suggestions. These processes reflect cultural understandings of illness in that period.² In the last 60 years we have witnessed a progression from a simple Freudian classification of impotence and frigidity, to Masters and Johnson’s expanded list of three sexual dysfunctions for each sex, to the further expanded nosology in DSM-5, which will soon be challenged by the yet unfinished schema in ICD-11. The sexuality patterns that we will be considering are those that are brought to our clinical attention, only some of which can be found in a committee-approved nosological schema.

Health and disorder perspectives on the sexual universe naturally divide into two broad dimensions: sexual identity and sexual function. Psychiatry, psychology, and the numerous master’s degree–prepared fields of psychotherapy usually begin the education of their students with the designated problems in these two dimensions because those fields were created to solve them. Wide variations in each of these major categories of sexuality are more apparent now than ever before in history; diversity is also seen in the behaviors that individuals engage in.³ In recent decades mental health professionals are pathologizing less and understanding more. This alone represents cultural progress.

Sexual identity has three components: gender identity, orientation, and intention (see Chapter 7 for further discussion). Passionate politics surround the variations in these components as different stakeholders defend or condemn those with nonconforming gender identities, homosexual interests and behaviors, and unconventional or paraphilic desires and behaviors. We mental health professionals are not expected to be a part of those who condemn because we are devoted to helping. In the past we have been condemnatory, most vociferously, about homosexual lives.⁴ Groups of people who in the past found themselves in classification systems of mental disorders are today more neutrally referred to as sexual minority members or their interests and desires are subsumed under the umbrella of sexual diversity.

Sexual function has four components: desire, arousal, penetration, and orgasm. Their problematic aspects are classified by genital anatomy. Male DSM-5 diagnoses are male hypoactive sexual desire disorder, erectile disorder, premature (early) ejaculation, and delayed ejaculation. Female DSM-5 diagnoses are female sexual interest/arousal disorder, female orgasmic disorder (anorgasmia), and genito-pelvic pain/penetration disorder. Both men and women have substance/medication-induced problems. DSM-5 creates other specified and unspecified categories for other patterns. Do not be misled by the terms male and female in these headings. Gender-nonconforming individuals may also qualify for these DSM-5 sexual dysfunction diagnoses.

Movies, television, fiction, biography, newspapers, magazines, talks with friends, watching dramas unfold in our family and the families of our friends, and self-knowledge all contribute to what we know about the causes of personal and interpersonal dilemmas that may limit sexual life. Some of these are accurate illustrations of how people suffer, and even though they may not deal with sexual identity and function directly, people intuit how sexual life may be affected. We also learn about sexual life from our knowledge of medicine, where sexually transmitted diseases, pregnancy and its complications, gynecological and urological diseases, and organ system failures interfere with self-concepts, pleasure, and sexual capacities. And, depending on our knowledge of different cultures, we may realize how the ideas unique to these cultures may facilitate or constrain sexual development. All of us have ideas about what influences sexual life. One of the things that limit our understanding of these influences is the enormous variation in every aspect of sexuality.

The questions for professionals are 1) Do we know something that observant laypersons do not know? 2) Do we have esoteric information or a frame of understanding that is more or less unique to us? 3) To what extent can clinical science help us? and 4) Is the knowledge generated by clinical science useful to the process of helping? I will provide you with my answers to these four closely related questions in Chapter 10.

We live our lives. At times, our feelings and behaviors create situations that we cannot master. This does not cause most people to seek assistance from a mental health professional. At times, others tell individuals that they need professional assistance. Even this does not necessarily result in their seeking our assistance. At best about half of physician referrals to a mental health professional are acted on and often not immediately. Numerous studies have illustrated that most people with “mental disorders” do not seek mental health care and that most people with sexual difficulties do not directly ask for help.⁵ We assume that those who do arrive for care inform us of the sexual vulnerabilities of the population who do not seek care. But we can never be sure how great a public health problem our patients’ concerns represent. My synthesis is that my patients represent the very tip of the iceberg of prevalence.

Happy, sexually well-adjusted, fulfilled people generally do not seek our services. Most seek us out in crisis or after bearing the weight of a serious dilemma for a long period of time. Three avenues to care provide us with our clinical experiences: 1) an individual or couple arrives with a chief complaint of a sexual identity or a sexual function concern; 2) an individual seeks treatment for another psychiatric problem and eventually discusses her sexual problem; or 3) an institution such as a hospital, school, corporation, or religious organization, or a lawyer or judge, remands a person for evaluation after his sexual behavior offended the institution’s or society’s values.

These pathways have taught us that there are recurring sexual patterns that are not well characterized in any nosology. These include the unconsummated marriage; a couple’s abandonment of sexual behavior; unreliable sexual function during infertility treatment; sexual aversion; orgasm with diminished pleasure; sexual addiction; sex crimes; persistent genital arousal; and individuals who become physically ill following orgasm. Even this list, however, does not capture the vital life-diminishing problems of infidelity, jealousy, pornography dependence, the love-lust split, and the impact of physical illness, including that related to a sexually transmissible infection. Nor does it capture a variety of context-specific subjective concerns that are impossible to completely list.⁶ Here are only a few: Can I sustain love for any partner? When should I fake orgasm? What will menopause do to me? How long will my waning potency last? Why can’t I enjoy this? Am I gay? Am I trans? Interest in clinical sexuality exposes the clinician to all the processes of life. One cannot listen to sexual stories from patients without eventually coming to appreciating this.

This book is not intended to train you as a sex specialist. It is intended to prepare you to be interested and helpful in your specific work setting, which will vary considerably from reader to reader. As long as you are open to listening to patients’ concerns, you may encounter all of the patterns mentioned in the previous section. Although you will not be able to resolve all of them, your efforts to understand can be helpful. Your rewards for trying will often be patient respect, gratitude, and future referrals.

Working with patients’ sexual concerns will show you that sexuality is not simply about sex. The topic is actually about the unfolding of the individual self, the capacity to give and receive pleasure, the ability to be psychologically intimate, the capacity to love and to be loved, and the ability to manage the expected and unexpected changes that occur throughout adulthood. You will soon begin to have convictions about what shapes a person’s fate. With just a little experience you will be able to get to the heart of a clinical situation more efficiently. You may realize the profound hopes for a better life that patients have during their work with you. You may find that your sexual life improves as a result of your changing perspectives. And you will remain professionally humbled by the fact that although you can help many, there is so much that you cannot positively influence. A sexuality focus is just one of many clinical pathways to these professional goals, but since every patient you will ever work with will have a sexuality, you are bound to discover a sexual universe that is well beyond your current understanding. You need only remain a respectful, curious student who is committed to assist, no matter your age, gender, orientation, or preferred ideology.