Controversies

Authored by Henry Strick van Linschoten

There are a number of controversies in the fields of sexuality and gender that may be relevant, or appear to be relevant, to psychotherapists and counsellors. Most of these have fairly clear resolutions – not that there are easy, single truths, or that there are not valid arguments on both sides. But in practice, key aspects of these controversies can at least be organised together, so that more clarity can be reached than in most mainstream public and media discussions.

One general theme is that of psychotherapy and the law. There is no doubt that psychotherapists and clients are subject to the law, its prescriptions, prohibitions and sanctions. Mostly it is clear which law this is, with there being a slight issue about applicable jurisdiction for people involved in online psychotherapy. Most psychotherapists would like to keep a clear separation between law and psychotherapy. Psychotherapists mostly do not have a legal function, nor are they part of the criminal justice system – forensic expert advice and forensic work excepted, which is not the focus here.

The law prescribes confidentiality, and this has been endorsed by all reputable counselling / psychotherapy organisations. But other than obeying the law, psychotherapists are not enforcers of the law. If the law has an effect on our clients, we would talk about that in therapy as we would other matters, with the interest of the client foremost in our mind, and without believing that legal judgements or court judgements are 100% infallible, or that legal views or meanings of words necessarily mean the same in a psychotherapy context. As stated in the section on Terminology, the APA warns about misusing the DSM-5 classification forensically. The purpose of DSM-5, ICD-10/11 and psychological formulations is different from what is needed in court cases. And a diagnosis or similar never provides a clear conclusion as to what degree of control a person may have or have had over their behaviour.

There is the question of safeguarding duty. Whilst this is quite restricted in the UK in general, there may be stronger obligations when counsellors are employed by an institution; but in that case their specific institutional context will give guidance and should give training about the extent of obligations. There may be difficulties in much work that relates to current or past circumstances involving violence, lack of consent or coercion that can also appear in the fields of sexuality and gender, and this will get some attention in the Issues section.

Paraphilias / perversions

The history of this terminology has been described elsewhere. The apparent controversy would be about the arbitrary extension of these words to other, inappropriate areas, whereas the major professional organisations have by now severely limited their use. Homosexuality has long been depathologised; it should never have been pathologised anyway, and was not by Freud himself, but at least this has been “sorted out” in a number of (mostly Western) countries. Most of what still are called paraphilias have been depathologised by DSM-5 and will be by ICD-11. There can be problems about controlling behaviour, but that is a rather different formulation. And what remain as “paraphilic disorders” are mostly the cases in which people have acted in a way that harms others, or without their consent, or cases in which a person is very severely distressed by their behaviour, feelings, fantasies or urges, or their work, social life or relationships are impaired as a result. In those cases, the focus of therapy would be on the issues mentioned (e.g. the non-consent; violence; lack of control; distress), and not on removing a paraphilic “pathology” as such as a primary or self-evident goal.

Sex work and sex workers

Sex work is the contemporary term for what used to be called prostitution, preferred by the people who engage in the activity. The term was probably created by Carol Leigh in 1978 but came only in wider use in the 1990s. It was coined at a feminist conference that was trying to limit violence against women and was fighting their objectification.

Sex work has a wide definition, without anything like agreement on what are its precise limits. Clearly one only uses sex work if it has a commercial and contractual side. But what kind of sex to include or exclude is at times contested. Certainly, it does not always imply genital, let alone penetrative acts. Pro-dommes and other BDSM acts are usually included. Pole dancers, and strippers sometimes consider that they should not be described as sex workers. Porn film “performers” are clearly sex workers. But are camera people? The sellers of sex toys? The manufacturers of sex toys? Brothel owners? And how about cam workers? Or people who chat to provide sexual stimulation? People offering cybersex or phone sex against payment? There is a general tendency to use a term of “sex industry” which is wider than the sex workers working in this industry; this distinction may be helpful, especially psychologically. With the general lack and often low quality of research in this field, the definitional problems are significant.

There have also been attempts to redefine sex work so that it is only called that if it is voluntary, contractual on an equal basis, legal, and supposedly consensual. As many forms of sex work are illegal in many countries, this does not seem useful for any attempts at comparative research. Although it is important to distinguish sex work from sex-trafficking (nature and purpose are too different), the legality and degree of voluntariness cannot be made a definitional condition.

Therapists can encounter sex work when they have prospective or actual clients, when clients with whom they are working reveal a past history of certain kinds of sex work, when clients pay for sex work, and of course when there are considerations of young people, coercion, trafficking, or blackmail. Considerations surrounding therapy with sex workers fall into the distinctions made in the module section on issues.

As has often been said, sex work has a very old history. Its legal status has varied over the centuries, between countries, civilizations, and even between religions (“sacred prostitution” has really existed – it is not a myth). Currently in the UK providing sexual services in return for payment is legal; loitering, soliciting or keeping a brothel are not; and certain forms of organising sex work, including forms that make it safer, are criminalised.

The “controversy” in this case is whether engaging in sex work can ever be an acceptable or fully autonomous choice. Legal problems belong to the legal sphere. In the last 50 years there has been a lot of condemnation of sex work as by definition exploitative, demeaning, objectifying, or plain “wrong”. One argument that would put this in a more relative perspective was the position of a minority of radical feminists, especially in the early 1980s, that all (heterosexual, male-female) intercourse was exploitative and coercive anyway. If that is the case, at least sex work would not be that different.

Then there is the frequently-heard retort that there are many other jobs that are demeaning and exploitative, certainly at the lowest-paid end of the “market”. And even the term “job market” itself may be read as betraying objectifying and exploitative aspects.

Furthermore, there is an impression (though not supported by reliable studies) that sex work on the part of university students has been increasing over the past two decades. The example of Belle de Jour, aka Dr Brooke Magnanti, who described her experiences and choices in Magnanti (2005, 2012) are a useful antidote to the condemnatory statements often heard about sex work. University students making a choice to (part-) finance their study this way seem to have other choices to make money too, and would be expected in general to have the capacity to analyse the choices they have in an organised and rational manner.

Sex workers in general have been and are becoming ever more vocal in stating that they know best, and that their voice should be listened to ahead of anyone else’s opinion. This seems a legitimate criticism of the sparse research that used to be conducted, and the voluminous reflections and opinions expressed by people who had neither personal experience of sex work themselves, nor even any first-hand contact with actual sex workers. Some examples of books written by sex workers are Davina (2017) and Grant (2014).

Trans

The existence of trans people, and some of the contemporary thinking on this point, are discussed in other sections. There are apparent controversies which bear no relation to any professional experience, knowledge or contact with trans people, e.g. arguing that gender dysphoria is “not real”, is “made up”, or is “pathological”. Apart from the need to respect the autonomy of the individual when differentiating the characteristics of the clients we work with, there is no support in any serious professional literature for such views.

There are women who call themselves feminists, women and men who come from a religious, political or conviction-based pathologising position, who ignore and disrespect the position taken about trans people in the laws of most western countries, and in most professional psychotherapeutic, psychological and medical organisations, about trans people who have acquired or identify with another gender than what they have been assigned to at birth. Their opposite, at times extreme positions, use formulations such as ’trans people do not really belong to their (new [sic!]) gender, or believing that forms of discrimination or distinction should be made in bathrooms, single-gender spaces, prisons or other institutions on the basis that trans women are “not really women” or (much more rarely) that trans men are “not really men”. Such positions are consistent with the higher incidence of mental health problems, violence, assault, harassment, work discrimination and murder that trans people experience. These are at the same level as experienced by many other groups that are discriminated against and persecuted. Therapists and counsellors should be sensitive to these problems and support their trans clients as well as they can; if they feel they cannot, they should refer.

Homophobia and biphobia

These expressions have taken clear root in the language, but it is good to remain aware of how unsatisfactory they are. Neither of them are “phobias” in any normal sense of the word. Even more and more jurisdictions are now limiting or stopping any use of elements of “homophobic panic” as a possible defence for violence. These words, as they are used, really correspond to strong feelings, fear, anger or rage, about other people’s behaviour, lifestyle or identity, for which there is no place in a diverse civilised society. The rationalisations used to somehow justify or excuse these responses are blatantly oppressive, and should be qualified as hateful prejudice, as with any attempts to justify racist acts.

Homophobia and biphobia have different histories. Homophobia has had attention paid to it at least since the 1960s when it was coined. Herek (1990) usefully puts the term in context. The idea of “internalised homophobia” has been much discussed, also in a psychotherapeutic context. Many statements that include a commitment to human rights, and policies of institutions and companies, have been put in place to diminish or eliminate homophobia.

Biphobia is of more recent coinage: the word originated in the mid-1980s, was modelled on homophobia, and started to be used regularly in the 1990s. The concept is weaker than homophobia, much less used, and has received considerably less policy attention, despite bisexuals being more numerous than gay people, and the prejudice, impact and violence being at least as severe.

There is a long article about bisexuality in Wikipedia which is useful in giving an idea of the wide range of issues and material. Eisner (2013) is a good book by an activist. Diamond (2008) is a foundational text about sexual fluidity. And an up-to-date overall perspective is given by Barker and Iantaffi (2019).

Homosexual behaviour, gay, lesbian and bisexual identity, and bisexual attraction all exist. And there is nothing pathological or strange about it; nor do they need any explanation or justification. They are part of living on a planet as members of a species with a substantial degree of diversity, and no more in need of justification than eye colour, hair colour, stature or any other differences.

There is no (ethical) room for homophobia or biphobia in psychotherapists. If a counsellor belongs to a (usually religious) group that “believes” in proscribing or outlawing certain generally accepted consensual behaviours and inclinations, that is a problem for the counsellor to deal with. If a therapist does not know enough about certain types of people, whoever they are, and feels unable to work with them constructively, they have an obligation to refer them to others. Conversion therapy has been proscribed by all reputable psychotherapy organisations in Britain. In the population at large, so-called homophobia, biphobia and transphobia continue to exist. Dealing with unreasonable, antagonistic, violent and / or illegal behaviour that a client has been or is subjected to, or with prejudice encountered from family members or friends, are of course practically important subjects to support clients with. But they are problems of the aggressors / perpetrators, not problems in our clients.

“Porn addiction” and “sex addiction”

AASECT (the “American Association of Sexuality Educators, Counselors and Therapists”) is one of the major American organisations training and accrediting sex therapists. In their “Position on sex addiction” of November 2016, they stated in part:

“AASECT recognizes that people may experience significant physical, psychological, spiritual and sexual health consequences related to their sexual urges, thoughts or behaviors. AASECT recommends that its members utilize models that do not unduly pathologize consensual sexual behaviors. AASECT 1) does not find sufficient empirical evidence to support the classification of sex addiction or porn addiction as a mental health disorder, and 2) does not find the sexual addiction training and treatment methods and educational pedagogies to be adequately informed by accurate human sexuality knowledge. Therefore, it is the position of AASECT that linking problems related to sexual urges, thoughts or behaviors to a porn/sexual addiction process cannot be advanced by AASECT as a standard of practice for sexuality education delivery, counseling or therapy.”

Sex addiction was informally talked about in circles of Alcoholics Anonymous in the 1970s. Patrick Carnes (1983) wrote a book proposing the idea of “sex addiction”. Since then he has made it his lifework to popularise the category and to create various organisations and forms of training to train in, and to issue qualifications in the treatment of sex addiction. He and his followers have lobbied for decades to get the concept accepted officially by others. He has never had an academic position himself. No edition of DSM or ICD has accepted either sex addiction or porn(ography) addiction as a useful or valid category. Nevertheless, the media, popular literature, movies, and even lawyers, have been fascinated by the idea that these concepts would have real support, and continue to use them extensively as if they have some official status.

A useful site documenting research that explains many of the problems with the concepts and the ideas associated with them is the following Of the many articles referenced on that website, the following are especially relevant: Landripet, Buško and Stuhlhofer (2019), Landripet and Štulhofer (2015), Prause (2019), Prause et al. (2017), Prause & Pfaus (2015), Steele et al. (2013), Winters, Christoff and Gorzalka (2010).

The view of many research articles points in the direction of the possibility of such problems being linked with OCD, or more generally, of compulsivity and control over behaviour. An important book that avoids using addiction concepts is Braun-Harvey and Vigorito (2016), who talk about “out of control sexual behavior.”

References

AASECT (American Association of Sexuality Educators, Counselors and Therapists). (2016, November). AASECT Position on sex addiction. Retrieved from https://www.aasect.org/position-sex-addiction

Barker, M.-J., & Iantaffi, A. (2019). Life isn’t binary: On being both, beyond and in-between. London: Jessica Kingsley.

Braun-Harvey, D., & Vigorito, M. A. (2016). Treating out of control sexual behavior: Rethinking sex addiction. New York: Springer.

Carnes, P. (1983). Out of the shadows: Understanding sexual addiction. Center City, MN: Hazelden.

Davina, L. (2017). Thriving in sex work: Heartfelt advice for staying sane in the sex industry. Oakland, CA: The Erotic as Power Press.

Diamond, L. M. (2008). Sexual fluidity: Understanding women’s love and desire. Harvard, MA: Harvard University Press.

Eisner, S. (2013). Bi: Notes for a bisexual revolution. Berkeley, CA: Seal Press.

Grant, M. G. (2014). Playing the whore: The work of sex work. London: Verso Books.

Herek, G. M. (1990). The context of anti-gay violence: Notes on cultural and psychological heterosexism. J. Interpers. Violence, 5(3), 316–333. doi: 10.1177/088626090005003006

Herek, G. M. (Ed.). (1998). Stigma and sexual orientation: Understanding prejudice against lesbians, gay men and bisexuals. Thousand Oaks, CA: Sage.

Landripet, I., Buško, V., & Štulhofer, A. (2019). Testing the content progression thesis: A longitudinal assessment of pornography use and preference for coercive and violent content among male adolescents. Social Science Research, 81, 32–41. doi: 10.1016/j.ssresearch.2019.03.003

Landripet, I., & Štulhofer, A. (2015). Is pornography use associated with sexual difficulties and dysfunctions among younger heterosexual men? J. Sex. Med., 12(5), 1136–1139. doi: 10.1111/jsm.12853

Magnanti, B. (2006). Belle de Jour: The intimate adventures of a London call girl. London: Weidenfeld & Nicolson.

Magnanti, B. (2012). The sex myth: Why everything we’re told is wrong. London: Weidenfeld & Nicolson.

Prause, N. (2019). Porn is for masturbation. Arch. Sex. Behav., 1–7. doi: 10.1007/s10508-019-1397-6

Prause, N., Janssen, E., Georgiadis, J., Finn, P., & Pfaus, J. (2017). Data do not support sex as addictive. 4(12), 899. doi: 10.1016/S2215-0366(17)30441-8

Prause, N., & Pfaus, J. (2015). Viewing sexual stimuli associated with greater sexual responsiveness, not erectile dysfunction. 3(2), 90–98. doi: 10.1002/sm2.58

Steele, V. R., Staley, C., Fong, T., & Prause, N. (2013). Sexual desire, not hypersexuality, is related to neurophysiological responses elicited by sexual images. Socioaffective Neuroscience & Psychology, 3(1), 20770. doi: 10.3402/snp.v3i0.20770

Winters, J., Christoff, K., & Gorzalka, B. B. (2010). Dysregulated sexuality and high sexual desire: Distinct constructs? Arch. Sex. Behav., 39(5), 1029–1043. doi: 10.1007/s10508-009-9591-6