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Biological, psychological and sociological background

Authored by Henry Strick van Linschoten

“Sexuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction.” This is taken from the WHO (2006) working definitions, and the WHO in another part states the centrality of a concept of “sexual health”, which is very widely defined, and involves a focus on well-being, rather than being principally concerned with the absence of disease, defects, deficiencies, pathology and dysfunction. Unfortunately the WHO statements show their age by only talking about freedom from coercion, and not using the more helpful concept of consent.

The WHO definition of sexuality is useful as it gives a general outline of what sexuality “is about”. For research and classification purposes, something clearer and more measurable is needed. The Klein Sexual Orientation Grid (Klein, Sepekoff & Wolf, 1985) is one of the best worked-out and much-used scales to “classify” different forms of sexuality. It separates sexual attraction, sexual behaviour, self-identification and some other factors, and gives a much richer picture than the simplistic division into heterosexuality, homosexuality and bisexuality. It puts all factors in the grid on a scale, instead of using binary oppositions. Very importantly it emphasises that the different factors can change over a person’s lifetime, i.e. it introduces a dynamic element.

Nevertheless, it suffers from the major limitation that the ends of the scale are the binary opposites of male and female, and there is no space for other genders. This is a general problem, which has not been resolved yet, but unfortunately limits the otherwise rich potential of using the Klein Grid.

Major concepts

Three central concepts are sexuality, sex and gender. More recently, all three have reached a rather complex stage, in line with the latest insights that are relevant to counselling and psychotherapy.

A hundred years ago

A hundred years ago the majority view was simple. Sex was defined biologically, based on a binary “evident” choice between male and female. Gender was not used in the context of sexuality, but only in grammar. The only “right” sexuality was heterosexual sexual attraction and heterosexual behaviour. “Normal”, “healthy” sexuality was between a man and a woman, would involve the genitals, was about a penis “penetrating” a vagina, and mostly was regarded as needing to be linked with reproduction, with pleasure neither as a motive for sexuality, nor even as something that was necessarily expected to be there. Masturbation was still looked at askance. (Nowadays the penis/vagina, genitally oriented and reproduction focused view of sexuality is still held by the Roman Catholic Church and many other conservative religious groups, and still influences the DSM-5 definition of “normophilic sexual interests” (DSM-5, 2013, p. 685); a good debunking of the opposition between normophilic and paraphilic is Joyal (2015).

The late 1970s

By the late 1970s, a number of changes had occurred. It was clear, at least to medical insiders, that the biology of genitals and secondary sex characteristics does not come in neat binaries, but that there is a sliding scale from more to less in classifying genitals as penis or clitoris. Chromosomal sex classification had started; but it was also clear that sometimes sex chromosomes do not “produce” the expected outcomes; and that many unusual and exceptional variations exist alongside the binary XX and XY constellations. This means that the factual underpinning had been laid to not see male and female any more as the two only, binary “possibilities” for sex – the practical conclusions from this were however not drawn at that time – largely sex stayed binary-defined, as it had been previously.

The word gender started to be used; sex being used for what was based on biology and visible characteristics, and gender based on what was starting to be realised was largely a biopsychosocial construct – a biological construct as there remains a biological basis to all thinking about sex; a psychological construct, as clearly the individual psychological construction of a person’s gender is a central factor; and socially constructed as a way of saying that societal and cultural factors play an important part in how people think about genders.

Sexuality started to be defined more neutrally, with major categories like heterosexuality, homosexuality and bisexuality starting to be recognised as possible sexual identities or forms of sexuality – and the still ongoing battle to depathologise and demedicalise these forms of sexuality started in earnest. Alongside the older word of transsexual, the word transgender was introduced in the late 1960s, and rapidly became part of established usage. However, what was not given any attention, was that this edifice remained based on a binary conception of sex, of male and female and nothing in-between or different. Homosexuality was about sexual behaviour with or attraction to “the” “same” sex. Heterosexuality was the preference for people of “the other” sex. Multiple genders were not on the map.

Current position

Now, well into the 21st century, and after a recent 15-20 years with considerable further change, new positions have been reached, though not fully consolidated.

After many changes in the definitions of sex and gender and their demarcation, there is now mostly a settled view that sex is used for a description of a person’s biological characteristics, specifically the chromosomal, gonadal and hormonal variables that together constitute someone’s biological sex. This leads to most babies getting a sex assigned at birth – in modern terminology people are classified as AFAB or AMAB – for “assigned male or female at birth”. For the small but significant proportion of people with variations in their sex development, this assignment can be controversial, and can lead to unnecessary and / or unethical medical treatment – with a major potential for later psychological problems that may emerge in therapy and counselling. The existence of a substantial range of biological variation shows that the distinction between male and female is not as binary, and as evident, as is often thought – even in biological terms. The existence of many people who earlier or later in their life become certain that their gender is different from their sex assigned at birth, proves that gender is not purely or mostly determined by a person’s biology.

Here are the main current positions:

  • Sex is based on biological characteristics but is seen as much less firmly “either male or female” in a binary or dualistic way, than it was formerly seen.

Gender

  • Gender is used mainly as a biopsychosocial construct, with the social construction of it weighing most heavily, but still rooted in and related to its biological basis – just like in psychology and psychotherapy one can never separate cleanly between mind and body, but always needs to remain aware of the complete mind-body connectedness.
  • There are many genders, without a clear restriction on their number. This is evident from the strong social constructedness; and practically, individually, by the role played by the individual, and the individual’s self, in a self-identification that feels completely, congruently, authentically, “right” for that person. Terminology for people who do not identify as clearly male or clearly female is still unsettled. Non-binary, gender non-conforming, genderqueer, and other expressions can be used; generally it is best to conform to a person’s personal choice.
  • Many people like to define for themselves the pronouns that they believe should be used about them, and which they consider are appropriate for them. It is regarded as reasonable, and basically respectful, to listen to a person’s choice in this matter, about themselves, and about others in their life, e.g. family and / or partners, friends, etc. These pronouns are defined as that person’s pronouns. “Preferred pronoun” is now deprecated, as it relativises the position too much. In comparison, a person has a name, which they communicate when introducing themselves. That is their name, not their “preferred name”.
  • The words “transsexual”, and “trans*” with an asterisk, are less and less used. Transgender is still used, alongside trans, for the whole group. And “trans” is mostly taken to include non-binary, gender non-conforming or third gender people. This means that at the moment estimates of the size and prevalence of being trans are particularly uncertain. Not long ago when it became clear that the prevalence of intersex was severely underestimated, it was occasionally said that there were more intersex people than traditional binary-defined trans people. However, when including all people with genders different from that assigned at birth, probably the trans population is larger than the intersex population. But wide uncertainties remain; there are no reliable estimates of the size of either the trans or the intersex population.
  • For all trans people it is respectful to follow their self-designation of their gender (and of course their pronouns). Trans people are either described with their chosen gender as such, e.g. “Alex is a man”, or “Sam is non-binary”, or if it is felt that their being trans is relevant, they can be described as a “trans male”, or a person who is “trans and gender non-conforming”. And in a personal as well as therapeutic context, especially on first acquaintance, it is good to be conservative in one’s judgement if trans vs cis status is relevant.
  • Until recently, a frequent form of transphobia was the idea that it was acceptable, either socially in public places, or even on television or in other media, as soon as a person was established as trans or transgender, to ask them questions about their genitals or their transition status. It clearly is not acceptable to do so, and, despite its private character, it is important in a therapeutic situation to be cautious and restrained in asking questions. If a person wants to disclose specific details, or sees them as a problem, they can; if not, they should not be forced. This also goes for assessment processes and intake forms. It is questionable to what extent physical or biological details are relevant in many counselling and therapy contexts. If questions are asked on a form, it is best to use open-ended boxes like “gender” or “medical issues that you want to disclose”, and to make clear that the client or prospective client is entirely free what or how much to include on first contact, and what they want to include or disclose in the therapy process.
  • Under the term trans come traditional transgender people, regardless of how much or how little body modification they have undergone, and regardless of any and of which hormones they take – as well as people who see themselves as having a gender other than male or female
  • The designations of MTF and FTM (male of female and female to male) have fallen in disuse. The correct and respectful term is to talk about a trans man, a trans woman, or a trans non-binary person, or someone of any other gender really. And more and more it needs to be questioned how important it is in many contexts to identify or highlight a person’s status as trans – at a minimum consent should be obtained from a person, whether they like it to be used or not.
  • Questions of surgery, body modification, how far to go in one’s public role or roles, pronouns used, and hormones taken, are now felt as choices to be made by the individual – only guided by medical specialists as regards what the options are and what risks and side effects can be expected. Pressure to make changes is seen as undesirable, and in fact violating a person’s consent and personal autonomy. And certainly what is to be done or not done is not regarded as properly depending on the approval or sanction of any third party, not even a medical (or psychological) professional. This follows in fact the more general medical model that people always have a right to agree to or refuse medical interventions.
  • Even under this model of individual personal autonomy, questions will remain when a person’s mental capacity is impaired or questioned. Existing laws usually give guidance on how to establish that mental capacity is sufficient to make decisions. This still leaves issues about decision-making for minors.
  • Attempts are being made to shift more of the protection of the rights of trans and intersex people to legal rights and human rights, rather than medicalizing the issues and getting protection from medical specialists. The history of medicalizing issues has not been very empathic, respectful or constructive.
  • As the new concepts have not completely settled yet, and when individual autonomy is emphasised, and more partial and personal decisions are being made by trans people themselves about what physiological changes they wish to make, it becomes more and more difficult to capture the trans world statistically. There are no reliable estimates of how many people fall under the new expanded definition of trans, including all people with an other than binary gender, and trans people whose identity is other than their gender assigned at birth, but who do not make changes to their bodies, or who perhaps take hormones, but make no surgical alterations. However, it is clear that under this new definition the extent of the phenomenon is much bigger than assumed before.

Problems with the definition of sexuality

  • Sexuality, in the sense that is often called “sexual orientation”, is becoming difficult to define. Under the influence of the modern discussions about gender, the idea of male and female as binary alternatives is more and more being abandoned. But if they disappear, the basic meaning of heterosexuality and homosexuality becomes uncertain. “Same gender”? “The other sex”? If these two last terms lose their meaning, as they have, the normal definitions of homosexuality and heterosexuality lose their sharpness and must be revised. But how?
  • The major contribution that the Klein Sexual Orientation Grid has brought, is attention to the idea that sexuality is expressed in a number of ways, in attraction, in behaviour (e.g. “men having sex with men” who are adamant that they are not gay), in self-identification, in fantasy… It had always been clear that bisexuality was defined as attraction to both (now all) genders, not in terms of behaviour. But for the main traditional classes of sexuality, homosexuality and heterosexuality, the choice had been less clear – although most professionals had long understood that attraction was the more fundamental factor, even here.
  • For the time being the fallout of the changes in thinking about gender on the definition of sexuality has not led to any definitive solutions. It may be best to be cautious, to listen attentively to what people say about themselves, and to enter their world – basic virtues of most counselling and psychotherapy approaches anyway. To clearly and completely hear and be present to what a client says about their attraction to people, the people with whom they engage in forms of sexual relations, how they identify their own gender, and if there is some system in the gender of people they are attracted to or have sex with, will lead to a valid understanding of them. It may be, for a period of time, more difficult than it was to compare them with groups of people that have been studied and described, as the definition of such groups is in a process of change. But from the perspective of individual psychotherapy this may not matter so much. As long as we think in terms of individuality, of uniqueness, of difference, diversity and variation, we will follow more easily the self-identification of the person in front of us. Pathologising, believing that some people are “abnormal”, let alone “sick”, seems to violate basic principles of counselling and psychotherapy, as well as ethics.
  • Two studies that at least try to address the problem of the need for new definitions are Van Anders (2015) and Moser (2016). However, these are only theories. Even if promising, they have not been agreed on a wide scale, let alone used for any research projects that would give us information about population-scale statistics of the prevalence of the newly defined groups.
  • All this confirms and enriches what was long seen as a marginal view, that if sexuality is problematised, it is as reasonable to see problems and contradictions in heterosexuality as in other forms of sexuality. At a remarkably early stage the psychoanalytically influenced Professor Neil Hertz (1983) wrote an essay about these issues, the conclusions of which were consolidated more firmly in the classic Sedgwick (1990).

Biology

It is important to be able to speak easily with our clients about anything sexual, including sex organs, sexual activity, anatomy, etc. Modelling a relaxed and positive attitude in itself can be helpful. It may also be needed to engage in some basics of sex education, combined with or as part of psychoeducation. Like with any interaction involving sexuality, it is important to keep an open eye for the possibility or need for referral, to a sex therapist, a GP, or some other medical specialist. But if as part of that process the counsellor or psychotherapist gives the impression that they themselves cannot even talk easily about the topic and outlines of sexuality, this is likely to give an unhelpful signal – as if sexuality itself, or the behaviours or identity of the client, are problematic, and the therapist’s problems with talking about sexuality might be a negative model for the client.

In the section on Reading, Study and Learning you can find references about sex education, and how to talk about that. As a therapist, apart from a good knowledge of sexual anatomy, it is important to have a somewhat deeper knowledge of the developmental biology of the human sexuality system.

The main sex organs are divided as follows:

  • Primary sex organs, the gonads, usually renamed as ovaries or testes. Gonads produce the gametes, specialised haploid cells (with only a single set of chromosomes, not as pairs), usually differentiated as ovums (eggs) and sperm. Gonads also produce and regulate most sex hormones.
  • Secondary sex organs, often differentiated as penis, scrotum, vulva and vagina. A distinction is sometimes made between external and internal, and the word “genitals” technically refers to externally visible sex organs. In most mammals though, the non-erect penis is not externally visible – just as the clitoris in humans is not usually externally visible – which makes the classification based on the internal vs internal distinction more difficult to maintain. The secondary sex organs play a vital role in the copulation process, serving to move gametes in such a way that the haploid cells can make contact and merge. The secondary sex organs in females additionally play a role in the birth process.

Chromosomal sex is established at fertilisation – meaning the presence of XX or XY chromosomes, or one of the many other possible variants.

Developmentally it is important to know that male and female gonads start out in the embryo being undifferentiated between male and female. They only start differentiating at around week 7 after fertilisation, on the basis of programming by the chromosomes.

External genital differentiation takes mainly place between week 8 and 12 and is mediated by different levels of sex hormones. There is a common precursor to penis and clitoris, which can develop in a number of ways. The similarity between penis and clitoris is confirmed by the fact that both have an erect and non-erect state; that both have similar numbers of sensory nerve endings; and that both play an important role in sexual arousal.

There are a large number of sex hormones, at least 50, that have been identified. A few useful facts:

– Hormones already circulate in the body prenatally
– Levels of hormones are rarely constant; they vary according to internal and external stimuli
– Androgens (of which testosterone is one) are present in males and females
– Estrogens are present in males and females
– Major physical bodily changes during puberty and around the menopause are substantially influenced by shifts in hormone levels

Intersex or Differences in Sex Development

Intersex variations are the result of variations in sexual development. Some intersex people prefer to talk about “Differences in Sex Development”. The medically popular term of “Disorders [sic] of Sex Development” is disliked by many intersex people and organisations.

Differences in sex developments can have many forms and causes. Chromosomally there are a number of other possibilities than XX and XY. There are variations caused by differences in response to certain hormones, and there are natural differences in the development and relative or absolute size of different sex organs, as there can be of most body parts.

There is a strong impression that in the past medical specialists as well as parents had a tendency to overreact to any variations in sex development, especially the more visible ones, and wanted to “standardise” people as early as possible after birth, without there being a medical need for this, other than in the minds of the adults involved. As a result of these frequent overreactions, much contemporary discussion of intersex variations involves reframing the past through today’s eyes, and also applying current human rights standards to the question of what interventions should be considered, and who is authorised to do so. A major problem is of course that a new-born baby is many years away from any ability to give consent themselves. But current comparisons would be with female genital mutilation (which was sometimes motivated in the eyes of parents and community “elders” by the idea that it was in the child’s interest to “conform”, and would help dealing with a perceived excessive level of libido), or with parents who would have a child with an unusual hair colour, and propose an extremely intrusive and risky procedure with a severity like that of bone-marrow transplantation or chromosomal intervention, in order to change the hair colour to something more conventional. In both cases, even if it is clear that parents have considerable authority over children, and that the baby cannot consent, the current view is that it is wholly unacceptable to allow parents to use their authority in this way – for FGM as much as for intersex “corrections”.

If as a therapist you get involved with a client with some form of intersex variation, or with a client who has a child about which they try to form an opinion about medical intervention or not, it is clear that this cannot be ignored. If you get involved in the thinking, it is very important, and ethically mandatory, to be well informed about the subject. If you hear about such things and simply avoid any form of engagement, that would also be a choice. As with FGM, the choice of “staying out of it” is more and more regarded as one that it is not ethically acceptable to make.

Biology – continued

Sexuality is rooted in biology. Of the major organ systems which structure all animal biology, sexuality directly engages the endocrine system, the nervous system (especially the autonomic nervous system) and the sensory system. Linked to sexuality, human reproduction engages the reproductive system.

Bowlby (1969) wrote at some length about sexual behaviour, and classified sexuality as a “behavioural system” – using the terminology of ethology.

Sexuality, especially in humans, is mainly related to pleasure. In case of any doubt about this, other positions (such as the traditional one linking it to reproduction) do not fit with any study of the biological systems involved, and exclude or cast doubt on the “real” sexual character of a whole series of activities, such as kissing, masturbation, gay sex, anal sex, oral sex, kink/BDSM, infantile sexuality, post-menopausal sex in women, and any form of penetrative sex using contraception.

Usually the idea of “arousal” comes up when describing in more physiological detail what takes place in sexual activities. There have been numerous detailed and less detailed theories of the sexual response cycle or model. Even now there is no agreed single or overall preferred model that explains and describes all biological aspects of sexual behaviour.

The Masters and Johnson model of sexual response – excitement; plateau; orgasm; resolution – has been largely abandoned. Soon after their first publications, desire was added as another essential category (Kaplan in the 1970s). Arousal has largely been substituted for excitement. Courtship has been put forward; it has been proposed that a non-linear as opposed to linear progression is more accurately descriptive; the emphasis on orgasm has diminished; and a new concept of willingness has gained traction. The model of Rosemary Basson (2000) is worth reviewing, not as the definitive answer, but because she ably sets out the different phases and aspects of the debate and outlines a more flexible framework than the sometimes overly-rigid models of other theoreticians. Similarly, the “new view” of women’s sexuality associated with Leonore Tiefer is worth reviewing (Kaschak and Tiefer, 2001).

Sexual arousal is a combination of subjectively perceived emotions with physiological elements such as engorgement of genitals and other body parts. Arousal is also accompanied by changes in the levels of various substances in the body – though it is not certain whether the arousal causes the changed levels, or the changed levels determine the level of arousal. Peptide hormones such as oxytocin, prolactin, vasopressin, steroid hormones like testosterone, estrogen, the cortisol complex, and neurotransmitters such as serotonin are examples of substances fluctuating concomitantly with increases and decreases of arousal. Steroid hormones are often referred to as “sex steroids” or “sex hormones”, but this is inaccurate, as their effects are much wider than only on the sex response cycle. Many other substances and drugs influence arousal without being designated as “sex” substances.

Pleasure

Essential elements of modern thinking about sexuality that are helpful for therapists working with sexual aspects of their clients’ lives, are the emphasis on pleasure, and the now thoroughly documented idea that masturbation, and anything related to masturbation, is not only harmless, but makes a number of positive contributions to people’s lives. This has a direct influence on the evaluation of countless “issues” around sexual behaviour, such as pornography, sex toys, cybersex, erotic art and literature, the place of sexual fantasies and dreams. Also this re-evaluation of masturbation needs to include the idea that there is no “right”, “optimal”, “normal”, let alone “normative” frequency and type of masturbation.

For practising counsellors and psychotherapists, here are some questions that they can usefully ask themselves:

  • does my client want to explore sexual topics in order to grow or develop? Am I the right person as regards knowledge, values, training and personal experience?
  • does my client have sexual problems? In that case, am I sufficiently trained, qualified and experienced to work with that?
  • does my client centrally have issues that are of a non-sexual nature? If as part of their life some of their sexual or relationship practices or identities come up, will they disturb me to the extent that they would affect the other work?

Labels and differences

There is a major strand in psychotherapy and psychology deprecating the usage of diagnostic labels (e.g. Szasz, 1961; Goffman, 1963; Frances, 2013; Johnstone, 2014). Despite the necessity of standardised categories for doing certain types of research, the critical stance against labelling, partly rooted in person-centred counselling as much as in sociology, is especially valid in the areas of labelling sexual problems. However, it is less actively applied here. One of the best appeals in favour of sexual diversity was made by Gayle Rubin (1984) in a highly recommended book chapter.

There is an excellent case in many or most areas of sexuality that people are different, and that those differences are not “abnormalities” that need to be addressed, removed, “treated” or “cured”, but accepted as part of normal human variation. A number of examples where this can be applied:

  • desire for sex. If we believe that there is no “right” or “normal” level of desire for sex, the basis for the diagnoses of “female sexual interest / arousal disorder” and “male hypoactive sexual desire disorder” is undermined. Also note that in both these disorders the concern is with “too low” a desire for sex. At present DSM-5 carries no standard diagnostic category for an “excessive” desire for sex. Also under this category fall the existence of asexual behaviours or asexual identity of persons. There is a growing recognition that this exists, is another form of sexuality, and needs to be recognised and accepted as a possibility or a way of being that carries absolutely no pathological connotations (Cerankowski and Milks, 2014; Decker, 2015).
  • preference for duration of sexual activity or states
  • right time for ejaculation – too early; too late. This means a healthy scepticism towards the DSM-5 diagnoses of “premature ejaculation” and “delayed ejaculation”.
  • importance of erections. This implies scepticism about the diagnosis of “erectile disorder”.
  • importance of orgasm – as exemplified in the diagnosis of “female orgasmic disorder”, which also stands out for not having a direct male counterpart.
  • relative importance or frequency of certain types of sex compared with others. This compares with the DSM-5 distinction made between “normophilic” and “paraphilic” sexual interests and behaviours.
  • methods / media / senses used for arousal
  • rules about what sexual actions are unacceptable, what objects or paraphernalia are unacceptable (e.g. sex toys), etc. Two important aspects for reflection in this area are:
    • the acceptance of and agreement on the complete right of any person in sexual relations to say no to anything, and that nobody has to do something they don’t want to do
    • the idea that some people have not been educated about sex, or sexual variations, and derive their banning or refusal of certain activities from abstract rules (religious …), or on ideas that they picked up from parents, media or culture, that in fact bear no relation to them having tried, or having obtained the experience of doing something; in this case, it may be appropriate to point this out, and ask if a client is interested in opening up and discussing how reality-based and experienced-based their refusal or dislike is.

Working through certain of the above themes may need to be an active element in psychotherapy and counselling to work through all the above themes. And the practitioner can only actively support their client if they can be genuinely neutral, and see variations in the above areas as differences, rather than as problems.

A major very different category is that of painful or otherwise unpleasantly-perceived / uncomfortable intercourse (or other, non-PiV or non-penetrative, sexual actions). In the DSM-5 nomenclature this is now called “Genito-pelvic pain / penetration disorder” – including the problems previously (DSM-IV) called vaginismus and dyspareunia. Excluding the (not so frequent) situation of a person who likes pain, pain, discomfort or distress tend to prevent or diminish pleasure, and are in themselves problematic. When this comes up in therapy, a start can be made with discussing general categories of assertiveness, consent, always being entitled to say no, being listened to, having your wishes respected – some of which are outside the scope of this module – but may play an important part in the occurrence and especially persistence of pain as a problem in sex.

More specifically, this remains a difficult category to work with. It goes without saying that there may be medical / physiological reasons for the pain too. While we automatically think about psychological reasons, it is not safe or ethically acceptable to work in counselling with pain and discomfort without excluding the bodily side. And even if there is a form of medical intervention, the client will benefit from accompanying counselling support.

Multi-disciplinary interventions

There are few areas where multi-disciplinary inputs from psychotherapists, sexologists and medical practitioners are as desirable as in dealing with sexual problems or “disorders”. Sex therapists themselves are often concerned that their contribution is neglected or obliterated by exaggerated promises that medical and pharmaceutical “breakthroughs” will be able to deal with all problems without a need for psychological support or intervention (Kleinplatz, 2012b). However, when a person presents with highly painful intercourse, or directly identifies their pain as originating in physical issues, it would be ethically and practically wholly incorrect not to inquire if a client has been medically checked, and if not, to encourage them to see a doctor, in tandem with receiving counselling and therapeutic support.

Phosphodiesterase type 5 (PDE5) inhibitors such as Viagra, vaginal dilators, and many hormones are now easier to obtain without prescription and this may have advantages for client autonomy, ownership and sense of responsibility for what they are doing. Other interventions, including surgery, remain of course purely medically controlled, usually as part of public health systems for “corrective” surgery, and privately for cosmetic forms of surgery on the genitals – the frequency of which has been growing. Given that in an ideal world for most sexual problems there would be a full availability of a combination of more medical / physical and more psychological support, it is important that whenever a client tells a counsellor or psychotherapist that they are seeing a doctor or buying pills, the therapist is able to inquire and accompany whatever is going on – without imposing themselves, their values or their lifestyle. That may require as usual managing the counsellor’s countertransference, and of course enough knowledge of substances and terminology, to be able to immediately have some idea of the complexities involved.

Graham and Bancroft (2009) give a useful perspective on the relativisation of sexual dysfunctions, and on the borderline between medical, sexological and psychotherapeutic approaches, albeit couched in the language of DSM-IV and ICD-10.

Normal and abnormal

Normality or abnormality of various sexual interests, activities and identities are extremely difficult to document. After more than 60 years of DSM diagnostic categories, DSM-5 states about most sexual disorders and dysfunctions that the prevalence is unknown, or occasionally an extremely wide range of possible prevalence rates is postulated. This is exemplified by the rarity of population-wide surveys of sexuality. The Kinsey Reports (1948; 1953) were revolutionary in their day, but have never been updated, and now reflect a different era. Since then there have been two major surveys in the English-speaking world, Michael et al. (1994) in the USA, and the British NATSAL surveys, conducted during the years around 1990, 2000 and 2010, and described / reported for instance in Johnson et al. (2001), Mitchell et al. (2013), and in detail on the Natsal website. As one small example, in the latter report the planned questions about masturbation had to be abandoned because of the survey subjects’ “dislike” of the questions; in the American survey there were also clear reports about these questions being the most intensely disliked; therefore, quite possibly, they were not answered truthfully, accurately or completely.

Safer sex

Safer sex (note the more appropriate “safer” instead of “safe”) is desirable. It is not our role to (try) to “impose” it on clients. And if we notice definitely unsafe sex practices, especially in younger people, we need to be aware of its meaning, and probably probe and to some extent encourage reflection on it. The spectre of AIDS has recently become much reduced, with effective treatment and preventive drugs (PrEP) now being available to deal with HIV infection. A better understanding of, and the availability of vaccination for, the Human Papilloma Virus (HPV) are likely to substantially reduce the cancer risk increased by this often sexually transmitted virus. Safer sex refers to the risks of pregnancy as well as of STIs. Preventing STI transmission is always good; whereas protecting against pregnancy can be desirable or not, depending on the circumstances. There are many STIs, some of them endemic at levels as high as half of the population of major countries. Some STIs are medically very dangerous, especially if untreated. Some STIs are completely treatable, others can be dealt with at the symptom level, others cannot be treated or cured at all. A good basic knowledge of this area, including the names of the major STIs, of safety methods especially barrier-based, a positive and open attitude to talking about STIs and safer sex, and a respect for client autonomy, are all desirable qualities of general psychotherapists and counsellors.

There are bacterial infections, e.g. chlamydia, gonorrhea and syphilis, and viral ones, e.g. HPV, the different herpes strains, and HIV. Responsible sex also means regular testing. Barrier methods remain the primary method against STIs (different from contraception, which has more choices). In many cultures there is a dislike, especially amongst men, of barrier methods – with the usual concomitants of pressure, consent issues, potential for violence even, and cheating. The main types of barriers are condoms, dental dams, and female or internal condoms. The latter two are little used. Many STIs can just as easily be transmitted through oral sex.

Stages of life

Sexuality plays a different role, and has a different meaning, in the various stages of life. Freud already defined the recognition of infantile sexuality as a test for the ability to work therapeutically with clients. The postulated absence of any trace of sexuality during the latency phase or stage (a term only still used by some psychoanalysts) is probably inaccurate and ignores evidence to the contrary. Puberty and adolescence are key periods for the development of sexuality, and of a sexual self. However, sexuality develops during the whole lifetime, from before birth to death. It is well-known that although age influences sexuality, and the body in general, there are few people for whom sexuality and sexual feelings completely cease after a particular age. Old-age sexuality has issues of its own that need to be acknowledged, and, if necessary, spoken about in therapy. Hormones play a role in sexuality, but more in terms of their general effect on the whole body than specifically or uniquely only on sexual experience and arousal. Post-menopausal sexuality is as real and “normal” as it is before the menopause, although HRT (hormone replacement therapy) influences a number of factors that can make an impact on the quality and choices of sexual behaviours.

Non-physical factors influencing sexuality

There are many ways of influencing sexual feelings, arousal and sensations through not directly physiological means. Fantasy, the imagination, dreams, literature – erotic or primarily romantic -, arts, sports, exercise, horse riding, massage, dance in many forms… None of these are in any way to be deprecated or seen as fundamentally different or “not really” sexual. Fantasy can range very widely, and many people withhold some of their fantasies from some or all of their (sexual) partners, for fear of offending or annoying. There is no reason why one should share; at the same time, sharing fantasies and associations can play a positive role in a relationship and enhance the quality of intimacy and communication. Kahr (2007) summarises a large random survey of the British population, and confirmed that many fantasies are illicit, and contrary to any actions one would perform. Rape fantasies are a prime example in this category.

Pornography

Pornography is not fundamentally different from erotic literature or other artistic representations that have the potential of leading to sexual arousal or interest, including sculptures, paintings and photography – despite the long-standing enthusiasm to make definitional distinctions based on certain characteristics. Pornography has had a long history of being feared and decried by most religions. Culturally, pornography has often been a form of expression for broader fears and moral panics (Cohen, 1972), leading to (continuing) attempts to regulate or even ban it through forms of criminalisation, threats of punishment, and censorship. Latterly it has also been a target of many, but certainly not all feminists, in line with the criticism and attack mounted by MacKinnon (1987) and Dworkin (1981). Currently, apart from an increasing level of censorship by the British government, there is a fanning of fears of so-called “porn addiction” – for which there is no good research evidence (more detail in the section Controversies). When clients state a concern about their usage of pornography, this will need to be discussed, but based on neither an addiction model for which there is no basis, nor on an unjustifiable preconception that pornography is inherently bad or dangerous. Concerns about others’ use of pornography, whether children or spouses / partners, come in a different category again, and come up regularly in couple therapy and individual therapy with parents.

BDSM and kink

BDSM and kink (here used as synonyms; some people try to make minor distinctions between the two) are important and common forms of sexual expression and behaviour. A degree of fetishization of lingerie and of certain body parts (e.g. breasts), as well as role play where the culturally common construction of male as active and female as passive, is translated in a power dynamic which is part of sexual relations, are easily seen as fully belonging to the world of kink.

The letters BDSM stand for a combined series of two-letter acronyms – BD for bondage and discipline, DS for D/s, i.e. dominance and submission, and SM for sadism and masochism. Kink has now been substantially depathologised in DSM-5 and ICD-11.

If BDSM plays a harmonious and ego-syntonic role in the relationships of a client, it should of course be left alone – with a degree of “normalisation” appropriate when it comes up. However, it is equally possible that it could have a more central role in the work of psychotherapy. Despite most or all consensual BDSM being an acceptable and common form of sexuality and sexual expression, an individual person may be influenced by the negative stereotypes fed by contemporary culture, or simply hindered by their partner’s, family’s or friends’ reactions to hearing or finding out about it. In that case more and deeper attention may be necessary, including a careful review of what the specific activities entail, whether there are non-consensual or unduly risky aspects to it, and to the nature of the visibility of the activity, and the communication about it with whoever “found out”.

There are many perspectives on kink, and it is important that a counsellor or therapist has a reasonable familiarity with the more common variants and practices, even if they do not engage in any BDSM activity themselves. In the references there are several good sources to make a start; in addition, some contact with the places where kink is discussed, or where on a familiarisation basis kinky demonstration scenes are open for interested viewers, would really help in therapeutic engagement on this topic, and assist in regulating possible countertransferential responses.

Between two sexual partners there is not only the possibility, but the likelihood that their tastes in BDSM, as well as their desire as to frequency and role, are not identical. Such differences, just as much as differences in the level of libido, are a frequent reason for therapeutic support – whether one works with one person or with a couple. The accent here is on how two people communicate about and deal with their differences, not with an element of judging who is right or wrong, or more or less “normal”.

There has been some discussion around whether BDSM could properly be classified as a sexual identity. For the more active and conscious kink practitioners kink can be so important that it is part of their identity. For kinksters for whom this is not true (based on their self-perception), BDSM / kink can be viewed as a substantial range of sexual or sexualised activities or behaviours that give people pleasure.

Drugs

Under the heading of drugs and sexuality, there is the blurred line between prescription drugs, formerly prescribed drugs that are now made available over the counter (e.g. PDE5 inhibitors like Viagra), and plain recreational drugs which (also) have (or are thought to have) effects on sexual functioning. Aphrodisiacs are another name for a range of ingested substances. And the presence in DSM-5 of so-called “substance/medication-induced sexual dysfunction” points to the possible negative side effects of substance use.

“Chemsex” (outside Britain sometimes called PnP or PNP for “party and play”) is a specific technical expression for the combined usage of (crystal) methamphetamines, and one or more others, often the dangerous G (GHB or GBL), mephedrone and / or alkyl nitrites / poppers. This is an effective but for certain people strongly addictive combination of drugs that in today’s gay male scene is seen as quite problematic. It has attracted its own CPD and specialist practitioners. However, it should be well understood that there are many other communities where people use drugs to impact, vary, alter or enhance their sex life or sexual experience – and there always have been.

It is also important to keep an open eye for the influence of alcohol. Alcohol is a psychoactive and potentially addictive substance that benefits from its culturally and legally sanctioned use. It plays a frequent role in situations in which consent is violated or at least doubtful. Alcohol is a libido-depressant, and in general has a potential for reducing and undermining sexual pleasure.

Technology

Sexuality and technology is a growth area. Sex toys are continuing to become more sophisticated and popular and have a lot of potential for increasing sexual pleasure and well-being. The internet is becoming more and more influential. Pornography can be offered there in written form, as still images, as combined audio / video presentations, of people as well as in cartoon / graphic “created” form, and finally can be live streamed, in passive or interactive format. There is cybersex, either as a message stream or in the form of cam-sex, with or without an audience. Cybersex is the internet successor of phone sex, which existed for much longer. Virtual sex is somewhat different – it means using technology to produce a very lifelike combined “experience” of being with another person or persons, using virtual reality techniques and dedicated equipment to replace sense impressions from the actual environment by computer-generated images, sounds, and possibly other sensations. Sex dolls are becoming more and more lifelike; the latest versions can talk, with different voices that can be selected, and have an AI (artificial intelligence) repertoire for interaction with questions and producing a kind of human-machine dialogue. The first brothels offering sex dolls have opened, and the market for these (rather expensive) “toys” is growing.

From a standpoint of sex being for pleasure it is very hard to condemn any of these developments – nobody is inclined to debate or pathologise eating specially prepared meals, going out for dinner, drinking high-quality wines, playing golf, or deep-sea diving…. Technological or technologically-enhanced sex has advantages in that the risk of STIs and pregnancy tends to be much reduced or eliminated. And despite longstanding (in the case of pornography) attempts to demonstrate a negative effect of the “consumption” of such artificial substitutes for “real sex” (“the right type of sex”, as judged by the speaker?), there is no real evidence of systematic or large-scale negative effects. It may overall, over time, change the character and relative frequency of people’s sexual activities – but change has been a constant in human history; bicycles, cars, airplanes, television, radio and electricity did not exist in the Middle Ages.

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STUDY GUIDES