Sexuality / Sex Therapy

Overview of Sexualitiy / Sex Therapy: Sexuality is a reality of life. People often seek therapy for issues related directly or indirectly to sex. Ambivalence about sex is as universal a human experience as human experiences can be. Talking about sex and sexuality is often part of the experience of therapy.

Various difficulties related to sexuality may lead people to seek therapy or simply come up during the course of treatment. To name just a few examples:

• Anxiety about sex

• Unwanted sexual impulses or compulsions

• Impotence

• Lack of sexual desire

• Anxiety or uncertainty about sexual orientation

• Conflicting or imbalanced sexual desires between partners

• Recovery from sexual abuse or sexual assault

• Loneliness

• Body image issues

• Promiscuity

Even if none of these issues is present, sexuality plays an important role in our lives, our relationships, and, sometimes, in our conversations with a therapist. Sexual energy is powerful and can profoundly affect our mood, our thoughts, and our general state of being. Sexual fantasies and behaviors are not always deemed socially appropriate, and we may not feel comfortable talking about our deepest thoughts and feelings with friends or family. This can lead to anxiety, frustration, and even depression. Therapy is a safe place to talk about any difficulties, fantasies, fears, memories, or desires, sexual or otherwise.

Incidents of sexual abuse may lead to diagnoses of Post Traumatic Stress or, in extreme circumstances, Dissociative disorders. However, several diagnoses, most of which are relatively rare, relate more directly to sexuality.

The Medical Model and Sexuality: There are several Sexual and Gender Identity Disorders identified, they include:

• Sexual Desire Disorders: Aversion | Hypoactive
A lack of sexual desire.

• Sexual Arousal Disorders: Female Sexual Arousal Disorder | Male Erectile Disorder
An inability to be aroused, despite having sexual desire.

• Orgasmic Disorders: Female | Male | Premature Ejaculation
Inability to achieve orgasm, or the inability to delay climax beyond penetration.

• Sexual Pain Disorders: Dyspareunia | Vaginismus
Paraphilias: These mental disorders are characterized by sexual fantasies, urges, or behaviors involving non-human objects (coprophilia, Fetishism, Transvestic Fetishism), suffering or humiliation (Sexual Sadism, Masochism), children (Pedophilia) or other non-consenting person (Voyeurism, Frotteurism, Exhibitionism).

Perhaps the most controversial of the sexual diagnoses is Gender Identity Disorder. Many people who are Lesbian, Gay, Bisexual or Transgendered or who are advocates for those persons believe that the traits described below are not a “disorder”, but evidence of the fluidity and personal nature of gender identity. People who feel they are, at their core, the gender opposite their anatomy usually do not consider themselves mentally ill, but simply “trapped.” They point out that the required “clinically significant distress or impairment in social, occupational, or other important areas of functioning” is a certainty in our society, and argue that this is not evidence of a disease in the individual, but of ignorance and prejudice in the culture. Mental health professionals who are creating the next version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) are considering whether to maintain this diagnosis as is, change it somehow, or drop it altogether. Meanwhile, most Americans who seek a sex change operation are required by their medical team to enter therapy and gain the therapist’s approval for their surgery.

Diagnostic criteria for Gender Identity Disorder:

A. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex). In children, the disturbance is manifested by four (or more) of the following:

• Repeatedly stated desire to be, or insistence that he or she is, the other sex.

• In boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing.

• Strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex.

• Intense desire to participate in the stereotypical games and pastimes of the other sex.

• Strong preference for playmates of the other sex. In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.

B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex. In children, the disturbance is manifested by any of the following: in boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion toward rough-and-tumble play and rejection of male stereotypical toys, games, and activities; in girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing. In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.

C. The disturbance is not concurrent with a physical intersex condition.

D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Case Examples of Sexuality Issues:

Donald, 47, is anxious and depressed. He drinks alcohol to soothe himself. He has never had a serious girlfriend though he is intelligent, fine looking, and financially stable. The therapist’s questions about his romantic desires seem to cause Donald some embarrassments, and the therapist gently inquires further. Donald reveals tremendous feelings of shame about sexual feelings, which are traced to a strict religious background and two disturbing experiences in which Donald witnessed, as a child, another boy being molested by a teacher. Therapy helps Donald overcome his shame and fear and slowly begin to accept sexuality as a normal, healthy part of life. This leads to diminished anxiety and an improved social life.

Missy, 34, enters therapy because she is having attractions to women. She reports being happily married to a man, and is at various times ashamed, excited, confused, anxious, and overwhelmed by these new attractions. She is not sure whether to tell her husband, act on the impulses secretly, or try to engage her husband in “some kind of arrangement,” which she is “sure” he would like but may not be her “cup of tea.” Therapy helps Missy examine her feelings, the possible choices before her, and the best ways of communicating with her husband, whom she decides to tell. She and her husband talk about her attractions, and he is neither judgmental nor perverse. Missy and her husband come to no conclusion about how best to handle Missy’s attractions, but their relationship feels stronger to both of them for having had the conversation, and they both express confidence that their marriage can sustain any possible future.

Therapy for Sexuality: There is a wide range of Psychotherapy Treatment Models or types of therapy used in the treatment of sexuality issues. Most of these approaches fall into three historic camps of psychology: Psychoanalytic / Psychodynamic approaches; Behaviorism and; Humanism. Regardless of the type of therapy, there are some generally agreed upon elements of healthy therapy which are universal to all forms of psychotherapy. Before beginning sex therapy or any other issue, it is helpful to familiarize oneself with these elements.

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Sexuality / Sex Therapy Article Summaries