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Authored by Henry Strick van Linschoten

Following the outline presented in the section on Issues, you may want to do some deeper study, or on certain matters may like more details. Apart from the references offered at the end of the sections, here are some general sources that go into more detail than this module.

A number of general academic level textbook-style sources

Justin Lehmiller. The Psychology of Human Sexuality. Lehmiller (2018).

Simon LeVay, Janice Baldwin and John Baldwin. Discovering Human Sexuality. 4th ed. LeVay, Baldwin and Baldwin (2018).

Meg-John Barker and Christina Richards (Eds.). The Palgrave Handbook of the Psychology of Sexuality and Gender. Richards and Barker (2015).

Douglas Braun-Harvey and Michael Vigorito. Treating Out of Control Sexual Behavior: Rethinking Sex Addiction. Braun-Harvey and Vigorito (2016).

Books about recent developments in sex therapy

Peggy Kleinplatz (Ed.). New Directions in Sex Therapy: Innovations and Alternatives. Kleinplatz (2012).

Damon Constantinides, Shannon Sennott and Davis Chandler. Sex Therapy with Erotically Marginalized Clients. Constantinides, Sennott and Chandler (2019).

Books specialising in sexuality and gender, focused on psychotherapy and counselling

Christina Richards and Meg-John Barker. Sexuality & Gender for Mental Health Professionals: A Practical Guide. Richards and Barker (2013).

Joe Kort. LGBTQ Clients in Therapy: Clinical Issues and Treatment Strategies. Kort (2018).

Books about non-monogamous relationships

Janet Hardy and Dossie Easton. The Ethical Slut: A Practical Guide to Polyamory, Open Relationships, and Other Freedoms in Sex and Love. 3d ed. Hardy and Easton (2017).

Rhea Orion. A Therapist’s Guide to Consensual Nonmonogamy. Orion (2018).

Elisabeth Sheff. When Someone You Love Is Polyamorous: Understanding Poly People and Relationships. Sheff (2016).

Franklin Veaux and Eve Rickert. More Than Two: A Practical Guide to Ethical Polyamory. Veaux and Rickert (2014).

A generally useful book about sex in long-term relationships

Esther Perel. Mating in Captivity: Sex, Lies and Domestic Bliss. Perel (2007).

Books about queer and queer theory

Meg-John Barker and Julia Scheele. Queer: A Graphic History. Barker and Scheele (2016).

Juno Roche. Queer Sex: A Trans and Non-Binary Guide to Intimacy, Pleasure and Relationships. Roche (2018).

Books about gender, sexual diversity, trans, non-binary, genderqueer

Meg-John Barker and Alex Iantaffi. Life Isn’t Binary: On Being Both, Beyond and In-Between. Barker and Iantaffi (2019).

Anne Fausto-Sterling. Sexing the Body: Gender Politics and the Construction of Sexuality. Fausto-Sterling (2000).

CN Lester. Trans Like Me: A Journey for All of Us. Lester (2017).

Arlene Istar Lev. Transgender Emergence: Therapeutic Guidelines for Working with Gender-Variant People and their Families. Lev (2004).

Christina Richards, Walter Pierre Bouman and Meg-John Barker (Eds.). Genderqueer and Non-Binary Genders. Richards, Bouman and Barker (2017).

Gayle Salamon. The Life and Death of Latisha King: A Critical Phenomenology of Transphobia. Salamon (2018).

Julia Serano. Excluded: Making feminist and queer movements more inclusive. Serano (2013).

Lisa Wade and Myra Marx Ferree. Gender: Ideas, interactions, institutions. Wade and Ferree (2019).

Some sources about kink and BDSM

Muriel Dimen. Perversion Is Us? Eight Notes. In M. Dimen. Sexuality, Intimacy, Power. Dimen (2003).

Tristan Taormino. The Ultimate Guide to Kink: BDSM, Role Play and the Erotic Edge. Taormino (2012).

Janet Hardy and Dossie Easton. The New Bottoming Book. Hardy and Easton (2001).

Dossie Easton and Janet Hardy. The New Topping Book. Easton and Hardy (2003).

Books about sexuality and disability

Eli Clare. Exile and Pride: Disability, Queerness and Liberation. Clare (2009).

Alison Kafer. Feminist, Queer, Crip. Kafer (2013).

Robert McRuer and Anna Mollow. Sex and Disability. McRuer and Mollow (2012).

References

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

Barker, M.-J., & Richards, C. (Eds.). (2015). The Palgrave handbook of the psychology of sexuality and gender. Basingstoke, Hants: Palgrave Macmillan.

Barker, M.-J., & Scheele, J. (2016). Queer: A graphic history. London: Icon Books.

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

Clare, E. (2009). Exile and pride: Disability, queerness and liberation (2nd ed.). Durham, NC: Duke University Press.

Constantinides, D. M., Sennott, S. L., & Chandler, D. (2019). Sex therapy with erotically marginalized clients: Nine principles of clinical support. Abingdon, Oxon: Routledge.

Dimen, M. (2003). Perversion is us? Eight notes. In M. Dimen, Sexuality, intimacy, power. Haworth, NJ: The Analytic Press.

Easton, D., & Hardy, J. (2003). The new topping book. Emeryville, CA: Greenery Press.

Fausto-Sterling, A. (2000). Sexing the body: Gender politics and the construction of sexuality. New York: Basic Books.

Hardy, J., & Easton, D. (2001). The new bottoming book. Emeryville, CA: Greenery Press.

Hardy, J., & Easton, D. (2017). The ethical slut: A practical guide to polyamory, open relationships, and other freedoms in sex and love (3rd ed.). New York: Ten Speed Press.

Kafer, A. (2013). Feminist, queer, crip. Bloomington, IN: Indiana University Press.

Kleinplatz, P. J. (Ed.). (2012). New directions in sex therapy: Innovations and alternatives. New York: Routledge.

Kort, J. (2018). LGBTQ clients in therapy: Clinical issues and treatment strategies. New York: WW Norton.

Lehmiller, J. J. (2018). The psychology of human sexuality (2nd ed.). Hoboken, NJ: John Wiley.

Lester, C. N. (2017). Trans like me: A journey for all of us. London: Virago.

Lev, A. I. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. Binghamton, NY: The Haworth Press.

LeVay, S., Baldwin, J., & Baldwin, J. (2018). Discovering human sexuality (4th ed.). Sunderland, MA: Sinauer Associates.

McRuer, R., & Mollow, A. (2012). Sex and disability. Durham, NC: Duke University Press.

Orion, R. (2018). A therapist’s guide to consensual nonmonogamy. New York: Routledge.

Perel, E. (2007). Mating in captivity: Sex, lies and domestic bliss. New York: HarperCollins.

Richards, C., & Barker, M.-J. (2013). Sexuality & gender for mental health professionals: A practical guide. London: Sage.

Richards, C., Bouman, W. P., & Barker, M.-J. (Eds.). (2017). Genderqueer and non-binary genders. London: Palgrave Macmillan.

Roche, J. (2018). Queer sex: A trans and non-binary guide to intimacy, pleasure and relationships. London: Jessica Kingsley.

Salamon, G. (2018). The life and death of Latisha King: A critical phenomenology of transphobia. New York: New York University Press.

Serano, J. (2013). Excluded: Making feminist and queer movements more inclusive. Berkeley, CA: Seal Press.

Sheff, E. (2016). When someone you love is polyamorous: Understanding poly people and relationships. Portland, OR: Thorntree Press.

Taormino, T. (2012). The ultimate guide to kink: BDSM, role play and the erotic edge. Berkeley, CA: Cleis Press.

Veaux, F., & Rickert, E. (2014). More than two: A practical guide to ethical polyamory. Portland, OR: Thorntree Press.

Wade, L., & Ferree, M. M. (2019). Gender: Ideas, interactions, institutions (2nd ed.). New York: WW Norton.

The post Reading, study and learning appeared first on Confer.

Authored by Henry Strick van Linschoten

Human diversity is a reality – in psychotherapy, in sexuality, in the therapeutic relationship, and in relationships generally. Diversity is more often seen and defined too narrowly rather than too widely. Differences in genders, in ethnicity, in religion or spirituality, in class, in educational attainment, are more quickly identified. But these days there is a growing awareness of diversity in health, in personality, in able-bodiedness, in neurodiversity, in trauma and abuse background, in genes, in epigenetic, prenatal and perinatal history, in culture, in age… And last but not least, differences in sexuality, in orientation, in identity, in behaviour, in standards, in views about relationships.

Differences

The problem with diversity is not that it exists, i.e. that there are differences between people, but in what we do with them. In that respect the word ‘diversity’ is somewhat suspect, in that it can be used and is used as a euphemism, to deny, diminish or belittle the importance and severity of the issues. As long as we notice differences in a neutral way that is fine. The human mind operates cognitively to a great degree by noticing similarities and differences. But things go wrong when differences are arranged into a hierarchy of good and bad, better and worse, when they are the basis for applying prejudice, or when they trigger overwhelming feelings and we become cognitively impaired.

Dealing with differences is a real challenge for psychotherapists. Sexism (prejudice or discrimination based on a person’s sex or gender) can trouble the relationship on two counts: it is unethical; and it is likely to make the psychotherapy ineffective or impossible. Racism and ableism can be just as damaging, even when they are more indirectly related to sexuality and sexual or gender expression.

All forms of discrimination, prejudice and stigma are problems for the person, the group, or the societal structures who have the power and the privilege. They are not problems for the oppressed groups in the sense that they are the ones who need to change or adapt to the rulers / oppressors.

Intersectionality

Intersectionality can be defined as a full understanding of the complexity in living, people and relationships. It was given its name by Kimberlé Crenshaw in 1989, although the underlying concept had been around at least since the 1970s. Crenshaw (1989) is very clear and describes the essence. At its origin was Crenshaw’s statement that the feminist analysis of the discrimination suffered by women was insufficient for black women, and that the intersection of race and gender was linked to constitute a qualitatively different type of oppression. A recent book on intersectionality is Collins and Bilge (2016). More directly focused on sexuality and psychotherapy is das Nair (2012). Collins (2006) focuses on black sexual politics.

For the analysis of the structural basis of racism, “white privilege” (Bhopal, 2018; Eddo-Lodge, 2018) and “white fragility” (DiAngelo, 2018; Lipsitz, 2006) are key concepts. These books are important material for therapists to read, and are directly applicable to our work.

Diversity poses many issues for psychotherapists, more than can be discussed in this section. A major helpful insight is the idea that statistical frequency, and descriptive observation of how a majority of people choose to act, are not a good guide for norms and standards to set about what people express, nor of how an individual behaves, or of what can be expected of one individual human being. Being red-haired, being Jewish, being gay, being neuro-diverse, differences of sex development, are all statistically “qualities” of minorities. None of them justify discrimination, exploitation, or a limitation of people’s human rights and autonomy. The equal rights accorded to all humans in the Universal Declaration of Human Rights and the International Covenant on Civil and Political Rights make no distinction between differences which are unalterable and fixed, and ones that are the result of personal choices and decisions made by a person.

Clearly within the general spectrum of diversity, it behoves counsellors and psychotherapists to be deeply non-judgemental and accepting of the diversity of their clients in all respects, including their gender, sexuality, sexual and relational behaviour, as well as in their feelings and fantasies. This may not always be easy for the counsellor, especially if they differ substantially from their client, if they have different values, or if they have neither experience nor much knowledge of aspects of the identity and behaviours of a particular client. This goes so far as to mean that if there is enough difference, or lack of knowledge about aspects of a client or prospective client, a therapist may be under a clear ethical obligation to refer the client to another more knowledgeable, more similar or congruent practitioner.

So-called “conversion therapies”

There has been substantial clarification of the position of psychotherapy concerning so-called “conversion therapies” set out in the UK’s “MoU on Conversion Therapy in the UK” of October 2017 (Conversion Therapy, 2017). This clarifies the position on the whole range of expressions of gender identity and sexual orientation, for which it is stated that any forms of therapy designed to change them are unethical; such forms of therapy are also held to be potentially harmful. This is a major source of guidance, certainly in the UK, but valuable to consider in all countries, as to the attitude to take to the widest range of diversity in sexuality and gender of our clients.

Conclusion

The following conclusions can be formulated about the implications of gender and sexual diversity for counselling:

• Therapists should not judge their clients or attempt to change them as regards their sexuality or gender. On the other hand, reflective clarification of uncertainty can be a very positive contribution, when clearly called for.
• When working with clients who are very different, therapists should not use the therapy as a way of learning about diversity for themselves. Beyond a certain point therapists need to refer to others who have experience with a particular community or range of behaviours that they are unfamiliar with.
• It must be possible for the therapist to be neutrally and empathically present to narratives and parts of life in which clients talk about what they are doing in their relationships and sexual activity, even with major differences with the counsellor. Changing how people are is not on the agenda – the focus of therapy must be on the aspects of their client’s life that the client wants to work on.

The diversity that the counsellor has to accept and deal with, extends to the field of relationships – although that received much less attention in the recent Conversion Therapy (2017) MoU. It is sometimes held, especially by people with a religious affiliation, that sex must only take place embedded in a highly mutual, interactive, long-term, emotionally close and stable relationship. This is then contrasted with sex where there is less intimacy and commitment, and where the (sexual) partner or partners may be substantially objectified. Examples include anonymous sex, “swinging”, “polyamory” or (ethical) non-monogamy, and certain paraphilias (formerly called “perversions”) – distinguished, as in the latest DSM-5, from paraphilic disorders in which people are severely distressed, or do harm to others. Commercial aspects of sexual activity, up to and including forms of sex work (not “prostitution”) also need to be re-evaluated and seen in a new light. Dimen (2003), a clinical psychologist and relational psychoanalytic psychotherapist, is vociferous in her warning to avoid the idea of intersubjectivity as a new orthodoxy and a new semi-religious standard of judgement for sexual and intimate relationships. As was Benjamin (1988), half a generation earlier.

References

Benjamin, J. (1988). The bonds of love: Psychoanalysis, feminism, and the problem of domination. New York: Pantheon Books.

Bhopal, K. (2018). White privilege: The myth of a post-racial society. Bristol: Policy Press.

Collins, P. H. (2006). From black power to hip hop: Racism, nationalism, and feminism. Philadelphia, PA: Temple University Press.

Collins, P. H., & Bilge, S. (2016). Intersectionality. Cambridge, UK: Polity Press.

Crenshaw, K. (1989). Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago Legal Forum, 1989(8, 1), 139–167. Retrieved from https://chicagounbound.uchicago.edu/uclf/vol1989/iss1/8/

das Nair, R., & Butler, C. (Eds.). (2012). Intersectionality, sexuality and psychological therapies: Working with lesbian, gay and bisexual diversity. Chichester, West Sussex: Wiley-Blackwell.

DiAngelo, R. (2018). White fragility: Why it’s so hard for white people to talk about racism. Boston, MA: Beacon Press.

Dimen, M. (2003). Sexuality, intimacy, power. Haworth, NJ: The Analytic Press.

Eddo-Lodge, R. (2018). Why I’m no longer talking to white people about race. London: Bloomsbury.

Lipsitz, G. (2006). The possessive investment in whiteness: How white people profit from identity politics (2nd ed.). Philadelphia, PA: Temple University Press.

Memorandum of Understanding on Conversion Therapy in the UK Version 2. (2017). Retrieved from https://www.bps.org.uk/sites/bps.org.uk/files/Policy/Policy%20-%20Files/BPS%20Memorandum%20of%20Understanding%20on%20Conversion%20Therapy%20in%20the%20UK%202.PDF

The post Diversity appeared first on Confer.

Authored by Henry Strick van Linschoten

Ethics and morality are about right and wrong. Many ethical issues are controversial, perhaps especially in the field of sexuality. As counsellors we have a “Code of Ethics” (at least one!) to abide by – which will get less attention in this module, as it tends to be the most discussed, and gets a reasonable place in most of our basic training. Apart from up-to-date guidance from the ethics committees of our membership organization, there are a number of well-known books that give good guidance in this area, e.g. Bond and Mitchels (2014), Gabbard (2016), Jenkins (2018a), Jenkins (2018b), Mitchels and Bond (2010), Tribe and Morrissey (2015).

Ethics can have different bases: authority; general rules (but do they in turn rely on authority? If not, on what else?); an evaluation of the consequences of actions. Systems of ethics are very diverse, and it is unlikely that the ethical values of therapist and client will fully coincide. There are issues specific to doing research, which are highly important, but will not be covered here. It can be beneficial in the general field of ethics, unless you have a previous background, to read a general introduction to ethics such as Driver (2006).

Important guidance on ethical matters needs to come from self-reflection, from supervision, from consulting the counselling organisation(s) we belong to, and when needed from taking legal advice. It is important to separate legal obligations from ethical / moral ones, not to put us as psychotherapists in the chair of a doctor, or become a representative of the criminal justice system, or even to apply our own ethical standards to our clients’ behaviour. If we need to maintain boundaries and make these separations internally, this may lead to feelings that do not belong in the therapy room, but that we need to discuss in supervision and sometimes with figures of authority who are personally relevant to us.

Ethics and sexuality

One of the easiest and clearest of standards is that we should never have a sexual relationship or engage in sexual activity with a client – not even if we believe or claim to believe that it would be for their good, or that it was justified by being consensual. Maintaining this standard does not mean that we will not have feelings, fantasies or dreams that involve sex. These are not covered by the ethical prohibition, but need to be noted, taken seriously, and disclosed and reviewed in supervision.

Dual relationships

Dual relationships are a major topic. They always need to be managed, and as such must be identified and questioned, as is brought out in most Codes of Ethics. At the same time, they cannot always be avoided. Rather than a standpoint that they simply should not happen at all, it is important that when something happens that comes close to it, the situation is carefully reflected on, discussed in supervision, and managed. There are several good background books on this topic – which unfortunately often concentrate too much on the legal or formal position, and too little on practical matters. Some general, and practical, sources in this difficult area are Clarkson (1994), Gabbard (2016), Gabriel (2005), Lazarus and Zur (2002), Syme (2003), and Zur (2017).

Dual relationships can usually be discussed in terms of different roles. When therapists or counsellors have other roles than working therapeutically with a client, this is possible, as long as care is taken that there is no confusion, that client and therapist are entirely clear, and that there is no overlap or slippage from one role to another. This is true when the roles in question are quite far apart (e.g. being a plumber, electrician, running a restaurant, being a lawyer or accountant – as well as being a psychotherapist), or when they are much closer, and involve other activities that entail working with people, possibly one to one, or are “helping professions”. A major example of this are psychiatrists, who are doctors – a medical role, but many of them also practise psychotherapy.

Compatibility of psychotherapy with roles with a sexual component

It gets more difficult when a counsellor has other roles that directly focus on sexuality or sexual problems, and / or if these involve ways of working that would be prohibited in psychotherapy. This could be massage, reiki, hypnosis, hypnotherapy, but it would also apply to nursing, midwifery, physiotherapy or occupational therapy. There are also forms of working with clients such as different schools of body psychotherapy, and of sexological bodywork, with their own accrediting bodies, standards, codes of ethics, practices and techniques. Finally there are the roles of sexual surrogates, and a range of forms of sex work (formerly and still largely legally called prostitution) proper, including stripping, lap dancing and BDSM / kink sessions which may or may not involve genital contact. All these involve issues that have received little discussion but are clearly difficult and controversial.

As many of these dual roles and relationships take place without controversy, it must be assumed that dual or different roles, when clearly separated and discussed, can at least sometimes be managed. But there are concerns and fears that suggest differently, when sexuality is involved. There is little literature on this subject when the non-psychotherapeutic role directly involves or includes sexuality and / or body contact. There is a clear need for further study and professional discussion.

Touch

As a specific liminal condition, the subject of touch is notoriously divisive. Outside the issue of dual relationships, and with full agreement on the unacceptability of sexual relationships or activity, different schools of counselling, different practitioners and different institutes have held widely disparate views on the allowability of touch. There is no consensus, other than that it is one signal area where unreflective, naive, spontaneous or unconscious acting is risky and undesirable. Whatever is done or not done must be controlled and fully considered, taking into account the widest interests of the client, and of the therapy and therapeutic relationship, short-term, long-term effects, unconscious and transferential aspects. One of few serious attempts at reflective discussion has been Galton (2006).

Consent

Consent is highly central for good sex, as well as for ethical sex. There is a real shortage of good literature about consent – often it is assumed that it is ‘evident’ what consent is; and it is the cultural norm of many countries that if there is no overt distress, or if a person does not explicitly say no (which is rare in many cultures, including British culture), you are safe to assume that there is consent. However, the latter is not a good-enough or even acceptable basis. Ideas about “informed consent” advocated in bioethics textbooks (e.g. Beauchamp and Childress, 2013), used by lawyers and in hospitals (again often devised by lawyers), are mostly too legalistic for most people to be realistically helpful. One of the best practical and yet detailed texts on a higher standard of consent that takes into account relational psychology, is chapter 5 in Barker and Hancock (2017).

References

Barker, M.-J., & Hancock, J. (2017). Enjoy sex (how, when and if you want to): A practical and inclusive guide. London: Icon Books.

Beauchamp, T. L., & Childress, J. F. (2013). Principles of biomedical ethics (7th ed.). New York: Oxford UP.

Bond, T., & Mitchels, B. (2014). Confidentiality and record keeping in counselling and psychotherapy (2nd ed.). London: Sage.

Clarkson, P. (1994). The therapeutic relationship. London: Whurr.

Driver, J. (2006). Ethics: The fundamentals. Oxford: Blackwell.

Gabbard, G. O. (2016). Boundaries and boundary violations in psychoanalysis (2nd ed.). Arlington, VA: APA Publishing.

Gabriel, L. (2005). Speaking the unspeakable: The ethics of dual relationships in counselling and psychotherapy. Abingdon, Oxon: Routledge.

Galton, G. (Ed.). (2006). Touch papers: Dialogues on touch in the psychoanalytic space. London: Karnac.

Jenkins, P. (2018a). Ethics. In M. Robson & S. Pattison (Eds.), The handbook of counselling children and young people (2nd ed.). London: Sage.

Jenkins, P. (2018b). Law and policy. In M. Robson & S. Pattison (Eds.), The handbook of counselling children and young people (2nd ed.). London: Sage.

Lazarus, A. A., & Zur, O. (Eds.). (2002). Dual relationships and psychotherapy. New York: Springer.

Mitchels, B., & Bond, T. (2010). Essential law for counsellors and psychotherapists. doi: 10.4135/9781446288818

Syme, G. (2003). Dual relationships in counselling and psychotherapy: Exploring the limits. London: Sage.

Tribe, R., & Morrissey, J. (Eds.). (2015). Handbook of professional and ethical practice for psychologists, counsellors and psychotherapists (2nd ed.). Hove, East Sussex: Routledge.

Zur, O. (Ed.). (2017). Multiple relationships in psychotherapy and counseling: Unavoidable, common, and mandatory dual relations in therapy. New York: Routledge.

The post Ethics appeared first on Confer.

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

The post Controversies appeared first on Confer.

Authored by Henry Strick van Linschoten

Sexuality is such a fundamental part of human life, that it can touch or impact on almost any aspect of psychotherapy. But in practice, the following list of issues may be good to keep in mind when watching the videos and reading the other sections of this guide, as they keep recurring, and are main reasons why extra attention to the field of sexuality and sexology makes us better and more effective counsellors and therapists.

Listening for and recognising sexual and gender issues

The most important contribution of the videos in this module and sections in this guide may be a process of awareness-raising, so that sexual and gender issues, and their role in a client’s life and relationships, become fully present, can be talked about easily, and so that issues are recognised and opened up – of course only with the consent of and when so desired by the client.

Talking about sexual matters, even with partners or friends, let alone with strangers, remains a taboo in many countries, and quite clearly so in Britain. Hence it may not be natural for clients to believe that they can talk about sexual matters with their therapist, and in addition, they may not understand or believe that it may be related to the work of psychotherapy. It is therapeutically most desirable that the counsellor takes a principled stance of openness and is sufficiently trained and prepared so that no conscious or unconscious signals, verbally or through body language, are given to the client communicating the talking about “such matters” as less than welcome to the therapist.

As with all difficult topics (take for instance issues of trauma or abuse, especially when taking place inside the family), the therapist has a difficult balance to keep. The objective on the one hand is to be as open and receptive as possible. On the other hand, leading questions or an inquisitional style are unacceptable, and moreover, any signals or words that a client does not want to talk about something, must be fully respected.

Deciding when and to whom to refer a client

A central issue that this module attempts to give support on, is the difficult judgement about which matters, when coming up, can be dealt with be a (general) psychotherapist or counsellor, and which topics need to be referred to another practitioner. And in the latter case, out of the wide range of specialties, is it possible to decide on the spot – or after review, possibly including consultation with a supervisor -, which specialty to suggest the client to consider? Even for specialised sexologists it is getting more difficult to decide or make a sound judgement whether a particular problem might require, or would best be treated, by a medical intervention, possibly including drugs – as opposed to talking therapy, body therapy, or other methods. When would a sex therapist be best? Or workshops with an educational mission? It is not possible to give a worked-out programme to allow for a simple series of screening questions. It is for the user of this module to go through all audio-visual material with this question in mind: what can I learn from this that enables me to find the best possible support for my client?

The other aspect to keep in mind is that it would not work for any and all sexual issues to refer to other professionals with a major or even exclusive focus on sex and / or gender issues. Precisely because sexuality and gender are fully integrated into the personality, and as such are a deep part of who a person is, their self, and their overall life project and relationships, in many cases it would be desirable if the planned psychotherapy or counselling would proceed, when something sexual comes up, to continue, but with the sexual issues integrated with the overall process. It requires training and reflection, such as provided in this module, to assist the counsellor in making sound decisions in integrating sexuality in the general therapy, or in making the decision to refer. And also to consider whether in the case of a referral a client continues in the existing therapy, or the therapy is ended. And lastly, if another professional works on a sexual problem, and a therapist continues general therapy, is there contact or co-operation between the general therapist and the “specialist”?

As stated elsewhere, there is far less available literature or studies to help in these issues than is desirable. These remain key choices and decisions that stretch the professionalism of counsellors and psychotherapists. Training, reflection and preparation can help to let us make the best possible decisions – within the limits of what we can do.

Learning to normalise the wide range of sexuality and gender for clients

If we continue to be fully or partly involved with a client while they are working on sex or gender issues, it is important that we know enough about the issues involved to remain generally supportive, to have a sense of what to say and not to say, and to remain collegial to other work that is taking place. It is similar to, but at least as difficult as our relationship to what a client discusses with and decides about taking antidepressants, or their participation in AA, or even the therapy process one-to-one with a client who at the same time is engaged in couple psychotherapy with their spouse, partner or partners.

Counsellors and therapists should obey the general edict of being open to the whole range of human experience and ways of living, and of avoiding judgements as far as possible. We cannot try to steer clients away from or towards religion in particular or in general. We cannot advise our client what career to choose, whether to have children, whether to make certain conservative or risky choices in matters of finance or law. However, we have to take positions in certain cases, such as Intimate Partner Violence, abuse, child protection issues, and may need to at least be proactive when clients are openly racist or otherwise engage in unethical or exploitative behaviour.

In line with these general positions which of course are not further dealt with here, there is a general position to be as open as possible about a wide variety of sexual behaviour, to be open to the full range of modern gender identities and expressions, and to avoid advice and judgement, even if our own choices are different. And again, some issues need to be treated differently, especially any non-consensual acts with others, any non-consensual violence, and any abuse or deception.

Helping clients with sexuality, gender and connected relationship issues

The overall purpose of this module is to make us better and more effective therapists and counsellors. All the knowledge offered and recommended reflection in this module share this objective.

Managing transference and countertransference

This is a much-discussed topic, and perhaps derives importance from the concerns that many therapists have about transference as well as countertransference. However, let us picture the standpoint of a person with a positive (or positive and critical) attitude towards sexuality, who is fully all right with their own and other people’s sexuality, sexual and gender expression, over a wide range. In that situation, it is very unclear why or how there would be additional problems arising out of specifically the sexual aspect of transference or countertransference. They are very basic processes taking place in psychotherapy. Transference is always there anyway, as identified by Freud in his “Papers on Technique”, which explained that interpreting and otherwise using transference was an essential part of the process of therapy. Countertransference needs some special attention, and in many cases is more to be raised in supervision. But it is difficult to see what changes when transference or countertransference are sexual, as opposed to transference consisting of non-sexual feelings or impulses. Transference and countertransference are diverse. And in any case that brings us back to the general principle that it is not the existence of transference that matters, but the unique idiosyncratic transference or countertransference in a specific situation, at this moment, between this client and this psychotherapist.

There is a good deal of literature about erotic transference and countertransference, including by David Mann (1997; 1999), Maroda (1998) and Rosiello (2000). A stimulating book that hardly uses psychoanalytic terminology is Constantinides, Sennott & Chandler (2019).

References

Constantinides, D. M., Sennott, S. L., & Chandler, D. (2019). Sex therapy with erotically marginalized clients: Nine principles of clinical support. Abingdon, Oxon: Routledge.

Mann, D. (1997). Psychotherapy: An erotic relationship: Transference and countertransference passions. Hove, East Sussex: Routledge.

Mann, D. (Ed.). (1999). Erotic transference and countertransference: Clinical practice in psychotherapy. Hove, East Sussex: Routledge.

Maroda, K. J. (1998). Seduction, surrender, and transformation: Emotional engagement in the analytic process. Hillsdale, NJ: The Analytic Press.

Rosiello, F. W. (2000). Deepening intimacy in psychotherapy: Using the erotic transference and countertransference. Lanham, MD: Jason Aronson.

The post Issues for psychotherapists and counsellors appeared first on Confer.

Authored by Henry Strick van Linschoten

In the context of the complete module, this section will discuss the immediate and wider aspects of how trauma, abuse and PTSD can influence sexuality, sexual health and well-being, and give views about the relative importance, strength and weakness of associations often made, all with a view to what is useful for the psychotherapeutic practitioner in their work practice with clients.

Abuse and trauma

Abuse is a term that is used to emphasise the mistreatment, unfairness, improperness, or sometimes wrongness of actions inflicted by one or more people on other humans (or animals). Wikipedia manages to produce a list of 117 types of abuse. Abuse by definition is inflicted by people. Abuse is a subcategory of the traumatic or traumatogenic events which are an essential part of the criteria for PTSD.

Trauma emphasises the harm or injury done to the victim of trauma. Trauma requires sentience by the “receiver” of the trauma. Psychotherapists commonly use trauma for what others would specify as “psychological trauma”, and that usage will be followed here. Even for psychological trauma, there is a tension between focusing on the objective qualities of what has been done, the subjective experience of the “victim” of the trauma, and whether or not the trauma produces lasting consequences, possibly in the form of PTSD, complex PTSD, or other disorders or behaviour patterns that a person exhibits in the longer term and that were not there before the traumatic event or series of events (e.g., years after having suffered trauma a person may be diagnosed with a substance use disorder, or a sexual dysfunction, without formally fulfilling the criteria for PTSD).

There is a huge literature about trauma and abuse (see for instance the Confer online modules about Trauma and dissociation, and about Intergenerational trauma), which will not be referred to here. The most important distinctions are between chronic and event-related abuse; and between trauma with or without an interpersonal dimension (e.g. without: earthquake, fire, drowning, disease, accidents).

What is sexual in sexual violence?

A key distinction in the context of this module is sexual or non-sexual. This already involves complications as regards possible pathways for impact, effect and causality. It is easier to assume that childhood sexual abuse, or sexual aggression or assault, would influence a person’s sexuality, than if the trauma is more related to violence, or caused identifiable lasting physical and / or medical injury, whether to genitals or other parts of the body. However, this is far from being confirmed by research studies.

Some extra confusion may be caused by the often-discussed position that “rape is not about sex, it is about power, violence and control”. On an analysis of the literature, it turns out that this statement is seen much more in popular than in academic or scholarly literature. There seem to be few if any academic feminists and / or lawyers who take the position that it would be incorrect to say that rape is an act of sexual violence. Some of the many nuances of a feminist rethinking of the legal and non-legal concepts of rape can be found in Whisnant (2017), including extensive references.

In controversial areas such as the ones in this section, words and language are often surprisingly fluid. It seems that international nomenclature is moving towards a generic non-legally defined overall term of “sexual violence”, as the one most helpful for delineating a range of actions or events with enough commonality and stability to study and evaluate statistically.

Trauma and abuse, sexual and non-sexual, physical or more emotional and intangible, can all do damage to the person, their confidence, their sense of self, their feeling of security including attachment security, and their sexual health, well-being and self-confidence. For the impact on sexuality, it is enough to fully accept the basis of sexuality discussed here as the mainstream view – that sexuality is an integral part of the combined mind-body health and well-being of people, and that sexuality is closely intertwined with the whole personality and people’s sense of self

However, it is very important when causality goes in one direction, not to believe that you can turn it around, and work backwards. It is possible that a person’s sexuality is influenced by trauma. But how it is influenced – what effect it has – how severe it is, is different from person to person. Generally, PTSD and complex PTSD are not 100% certain (“deterministic”) consequences of being traumatised (further see the discussion on this in Confer’s online module on Trauma and dissociation). Even for the most severe types of traumatic events, PTSD follows never in more than 50% of people – and much less for less severe types of traumatic event. Different people can react very differently to the same trauma or traumatic event; the same is true for the effect of trauma and abuse on sexuality. And given that trauma can affect sexuality, one cannot conclude that every disturbance or problem in people’s sexuality has a background in traumatic events or abuse – far from it. Sexuality is influenced by many factors; almost everything in a person’s life history can influence sexuality, sexual preferences, behaviour and identity.

Psychotherapists need to live with this uncertainty and are trained to do so. They need to be closely listening to and being attuned to the unique individuality of the client in the room. Hear what they say. But avoid jumping to theoretical conclusions that sexuality could be “mapped back” to particular events, including childhood events, trauma and abuse. They might; they might not. As in other areas of psychotherapy, we need to distinguish what we observe from what theories we are familiar with – theories that usually only consist of a statistical or probable or possible association or correlation – not a single-cause causality that would allow one to work backwards.

Causes of sexual dysfunctions

There is a range of significant potential causes other than trauma or abuse that can be found for sexual problems, and that can have major effects:

• violence (which is at least as rife a problem in society and human history as anything involving sexuality)
• poverty
• attachment insecurity
• independent mental health issues
• medical problems
• genetic factors
• epigenetic factors
• prenatal influences in the womb
• learning
• parenting
• family dynamics
• culture
• religious factors
• dogmatic beliefs, including dogmatic beliefs supposedly supported by science
• power and authority
• superstition
• moral panics

The ease with which it has often been tried historically to associate unusual sexual behaviours with trauma or abuse has been paralleled by a neglect or denial of studying the negative impact on sexuality of religious ideas, attitudes, rules and misinformation. The influence of religion has been less often named and formally studied, but its impact is clearly there. And religion has a place in a list of possible causes of unusual behaviour, on a par with the many others listed above.

Some specific sources

The following is a list of sources that illustrate the picture outlined above, and give more detail as well as more specific examples.

Ruth Cohn. Toward a Trauma-Informed Approach to Adult Sexuality: A Largely Barren Field Awaits its Plow (Cohn, 2016)

O’Callaghan et al. Navigating Sex and Sexuality After Sexual Assault: A Qualitative Study of Survivors and Informal Support Providers (O’Callaghan et al., 2018)

Smidt and Platt. Sexuality and trauma: Intersections between sexual orientation, sexual functioning, and sexual health and traumatic events (Smidt and Platt, 2018)

Tepper. Sexuality and Disability: The Missing Discourse of Pleasure (Tepper, 2000)

Rausch et al. Women with exposure to childhood interpersonal violence without psychiatric diagnoses show no signs of impairment in general functioning, quality of life and sexuality (Rausch et al., 2016)

Layton. Trauma, gender identity and sexuality: discourses of fragmentation (Layton, 1995)

Balint. Trauma and object relationship (Balint, 1969)

van der Kolk. The complexity of adaptation to trauma: Self-regulation, stimulus discrimination, and characterological development (van der Kolk, 1996)

Laplanche and Pontalis. Fantasy and the origins of sexuality. (Laplanche and Pontalis, 1968)

It is worth referring back here to the Introduction, and its definitions developed by the WHO (2006) of sexuality and of sexual health.

Analysis of a detailed example

On the detailed scientific and research side, the following analysis of some specific issues may be of interest.

“Sexual trauma” is a good example of a problematic trend that can be found especially in the sexological field, but also widely in psychotherapy, psychology and psychiatry. Outside the areas of scientific standards, peer-reviewed research in respected academic journals, and reputation based on experience and professional standing, there is a wide (and growing) field of uncertain status – the media; “popular psychology”, aptly named; social media memes; gurus; commercial interests clever at manipulating news and at times research; and plain appeals to power and to authority, as found in religion, spiritual movements, but also in states and parastatal organisations.

In this other field almost anything goes and can be advocated and supported. It is the aim of this module (and of Confer in general), not to jump on bandwagons and follow fashions, but to apply enough critical screening to allow the users of Confer’s CPD to trust that there is a reasonable evidentiary or research backing for what is included.

“Sexual trauma” is a good example to analyse in some detail. Broadly, the popular meme would be that “naturally” sexual problems would be often, or even mostly, “caused” by sexual trauma. The word “caused” is rarely used, as it would only encourage readers or listeners to ask how the causation is established, and to apply critical thinking. But causation is very much implied.

Trauma as a cause is itself a problematic term, as it is too often taken as suggesting that trauma or traumatic would be a quality of certain events – as the Greek original meaning of the word as physical damage or injury suggests. However, psychological trauma really refers to a long-lasting and persisting damage done to the mind, or more likely, the combined mind-body, in the aftermath of and as a result of (caused by) an event, or series of events. As stated in the Study guide of the PTSD module, there are no examples of classes of events that even exceed 50% in their capacity to lead to PTSD. And most events only result in PTSD at considerably lower percentages. In talking about trauma, in order to produce clarity in what one means, it is essential to state if one means a potentially traumatogenic event or series of events, or if one means the PTSD (or possibly other well-defined and ascertainable set of symptoms) caused by the events. In which case it is never an event, but a person with an affliction, set of symptoms, or disorder, that one is talking about. It is possible to ask someone if they have been abused as a child; if they have been sexually assaulted; if they have been involved in a traffic accident or earthquake; if they have been tortured. But one does not ask a person to self-diagnose with PTSD – just as a medical doctor would not do that with a disease. Symptoms yes – like a high temperature; headache; pain in the knee. But not a diagnosis of a disease.

Similarly, even when one rejects DSM / ICD type diagnoses, and wants to move the whole world to switch to using “formulations”, I do not believe that anyone has seriously proposed that it would be possible to let people produce their own formulation. A person is the ultimate authority on what they feel, what they perceive and what they experience – but the whole idea of diagnoses, formulations, or any form of communicatively effective choice of words, is that they are interpersonally derived, and not only based on an agreement between two people, but that there is an element of comparability achieved by believing that if one person calls a particular pattern or set of symptoms X, another person would, based on the same interview or contact with the person concerned be fairly likely to use the same formulation or designation of X for that person (reliability).

Apply this now to sexual trauma. First, there is an apparently closely related term that is “military sexual trauma”. This has been used in a number of studies and articles and is clearly circumscribed. It is a legal term, defined in the United States Code, the compilation of all US federal laws, where it is used numerous times. It is defined as – “psychological trauma, which in the judgment of a VA [Department of Veteran Affairs] mental health professional, resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the Veteran was serving on active duty, active duty for training, or inactive duty training.”

The disadvantages of using this definition for any psychotherapeutic discussion are clear:

• It is a legal term; not medical, not psychological, not psychiatric, not psychotherapeutic
• In its definition it refers back to other legally defined constructs, such as assault, battery and harassment
• Its occurrence is made dependent on the judgement of a “mental health professional” working for a government department, who makes a judgement about whether the military sexual trauma is caused by the legally defined potentially traumatogenic events or not

There is a disturbing level of trauma caused by sexual assaults on (and sexual harassment of) American military personnel. To establish legal responsibility, to agree on levels of financial support, to agree on the funding for treatment or other rehabilitative activity, to keep statistics, and to work on the process of reducing military sexual trauma, this definition is not only useful, but essential. But nothing of the work done using this definition will generalise to psychotherapeutic work with people who have not been working for or trained by the US military.

Going to the more general term of “sexual trauma”, unfortunately this does not seem to be used to any degree in research work. Other than its use in “military sexual trauma”, it was used occasionally as a synonym for sexual abuse in publications before 1995. One of the very few later examples of its use was in Smith and Freyd (2013), where its usage, other than extensively referring back to sexual abuse, fits a number of times with Freyd’s choice of the keyword trauma in Freyd (1996)’s concept of “betrayal trauma”, which focuses largely on the violation of trust by people or institutions, and deals more with childhood abuse than with a general scope of sexual assault that includes periods in life later than childhood.

Even if there would be an operational definition of “sexual trauma”, or a connection with generally used and precisely defined other concepts, the general research work about trauma functions differently from what is implicitly assumed in the popular idea that there might be a connection between sexual trauma and sexual problems or dysfunctions. Almost all research in the trauma field first connects different classes of traumatogenic events (with the wide scope including childhood physical, sexual and emotional abuse; sexual rape and assault and sexual harassment; physical attacks and interpersonal violence; non-personal life-threatening events such as earthquakes or epidemics; torture, war and terrorism) with certain well-defined disorders such as PTSD, complex PTSD, depression, anxiety, dissociative disorders and others.

There do not appear to be studies directly linking some or all of the usual traumatogenic events with sexual dysfunctions or paraphilic disorders. It has been made abundantly plausible that traumatogenic events are correlated with a range of disorders and symptoms. There remains a hesitation about the significance of this correlation, as in the central case of PTSD the traumatic events which form part of the definition (“actual or threatened death, serious injury, or sexual violence) have not been selected independently of the prior knowledge that these events are likely to stress and disturb people. So there is already a degree of definitional circularity at the heart of the paradigmatic usage of trauma. (To clarify this: “Why does this person have PTSD? Because they were exposed to trauma. What is trauma? Any event that can lead to PTSD symptoms.” is not an example of scientific reasoning. There is clearly more to the concept and theory formation around PTSD than this – but again, in popular summaries of the theory the risk of this circularity is ever-present.) However, it is clear that overall, carefully used, PTSD is a helpful concept.

The origin of sexual dysfunctions in other disorders is hard to demonstrate – in fact should hardly ever occur. Why? Because DSM-5 clearly states in all the criteria for sexual dysfunctions that the diagnosis of the function as a sexual dysfunction is not appropriate, and cannot be given, if the sexual dysfunction is “better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance, medication or another medical condition.” To be clear what this means: If a person has erectile disorder (ED) because they have alcohol use disorder (are an alcoholic), they don’t have alcohol use disorder AND ED – with the alcoholism explaining or causing the ED; they only get diagnosed with the alcohol use disorder, which directly explains the difficulties with erectile functioning.

So, while it is true that traumatic or traumatogenic events can be regarded as the cause of PTSD, or other (especially anxiety-related or dissociative) disorders, if they subsequently lead to sexual dysfunction, under the definition system of DSM they should not lead to a diagnosis of sexual dysfunction. The symptoms are explained by the disorder – which in turn was the result of the traumatic events. “Sexual violence” is one of the traumatic events that are conditions for a PTSD diagnosis. But sexual violence refers to an event or events; not to the trauma – which is a name for a set of symptoms of a person.

To summarise; there is no research connecting “sexual trauma” (assuming that it is defined in a way that links with normal nomenclature) directly with symptoms of sexual dysfunction. This is always mediated by a form of disorder that can be directly related to traumatic events. And if there is such a disorder, under the DSM rules that means that the sexual dysfunction cannot be diagnosed or described as an independent disorder, explainable by something else.

The above analysis can be largely repeated for “sexual violence” – which, while not easy to define itself, at least refers to events rather than to psychological (or medical) symptoms. There still is no research that substantially establishes the cause of sexual dysfunction in earlier sexual violence.

Two examples of research studies directly referring to the above problems can be consulted. Laumann, Paik and Rosen (1999)is one of the rare studies in which it was attempted to directly correlate sexual dysfunction with traumatic events. It covered a sizeable group of people (1750 women and 1400 men). But it suffers from such grave methodological problems, including an inappropriate use of Latent Class Analysis, that its results do not stand scrutiny. Even so, the outcome was very limited, and with small effect sizes, taking the results at face value. Another study about military sexual trauma, Luterek, Bittinger and Simpson (2011), with a small group of female military veterans, shows some findings with a certain correlation between military sexual trauma and PTSD as well as DESNOS, but on the way to showing that result, appears to indicate that the gathered data about childhood abuse would show that there is no correlation between childhood sexual abuse and PTSD or DESNOS – which would contradict a range of existing studies of reasonable quality. It also is methodologically weak, involves a small sample, and does not in fact properly distinguish between military sexual trauma and other non-military sexual violence. There do not appear to be studies in this field of a significantly better methodological quality, or studies suggesting there are markedly strong correlations that can be fairly easily obtained.

References

Balint, M. (1969). Trauma and object relationship. The International Journal of Psychoanalysis, 50(4), 429–435. Retrieved from http://www.pep-web.org/document.php?id=ijp.050.0429a

Cohn, R. (2016). Toward a trauma-informed approach to adult sexuality: A largely barren field awaits its plow. Curr. Sex. Health Rep., 8(2), 77–85. doi: 10.1007/s11930-016-0071-4

Freyd, J. J. (1996). Betrayal trauma: The logic of forgetting childhood abuse. Cambridge, MA: Harvard University Press.

Kolk, B. A. van der. (1996). The complexity of adaptation to trauma: Self-regulation, stimulus discrimination, and characterological development. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society (pp. 182–213). New York: Guilford Press.

Laplanche, J., & Pontalis, J.-B. (1968). Fantasy and the origins of sexuality. The International Journal of Psychoanalysis, 49(1), 1–18. Retrieved from http://www.pep-web.org/document.php?id=ijp.049.0001a

Laumann, E. O., Paik, A., & Rosen, R. C. (1999). Sexual dysfunction in the United States: Prevalence and predictors. JAMA, 281(6), 537–544. doi: 10.1001/jama.281.6.537

Layton, L. (1995). Trauma, gender identity and sexuality: Discourses of fragmentation. American Imago, 52(1), 107–125. doi: 10.2307/26304374

Luterek, J. A., Bittinger, J. N., & Simpson, T. L. (2011). Posttraumatic sequelae associated with military sexual trauma in female veterans enrolled in VA outpatient mental health clinics. Journal of Trauma & Dissociation, 12(3), 261–274. doi: 10.1080/15299732.2011.551504

O’Callaghan, E., Shepp, V., Ullman, S. E., & Kirkner, A. (2018). Navigating sex and sexuality after sexual assault: A qualitative study of survivors and informal support providers. Journal of Sex Research, 1–13. doi: 10.1080/00224499.2018.1506731

Rausch, S., Herzog, J., Thome, J., Ludäscher, P., Müller-Engelmann, M., Steil, R., … Kleindienst, N. (2016). Women with exposure to childhood interpersonal violence without psychiatric diagnoses show no signs of impairment in general functioning, quality of life and sexuality. Borderline Personality Disorder and Emotion Dysregulation, 3(1), 1–13. doi: 10.1186/s40479-016-0048-y

Smidt, A. M., & Platt, M. G. (2018). Sexuality and trauma: Intersections between sexual orientation, sexual functioning, and sexual health and traumatic events. Journal of Trauma & Dissociation, 19(4), 399–402. doi: 10.1080/15299732.2018.1451724

Smith, C. P., & Freyd, J. J. (2013). Dangerous safe havens: Institutional betrayal exacerbates sexual trauma. Journal of Traumatic Stress, 26(1), 119–124. doi: 10.1002/jts.21778

Tepper, M. S. (2000). Sexuality and disability: The missing discourse of pleasure. Sexuality and Disability, 18(4), 283–290. doi: 10.1023/A:1005698311392

Whisnant, R. (2017, June). Feminist perspectives on rape (from the Stanford Encyclopedia of Philosophy). Retrieved from https://plato.stanford.edu/entries/feminism-rape

WHO World Health Organization. (2006). Defining sexual health: Report of a technical consultation on sexual health 28–31 January 2002, Geneva [Technical report]. Retrieved from World Health Organization website: https://www.who.int/reproductivehealth/publications/sexual_health/defining_sexual_health.pdf

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Authored by Henry Strick van Linschoten

Starting from the clear and simple proposition that crimes are not mental disorders, and that mental disorders are not crimes, this section mainly tries to cover the many misunderstandings that exist in the sphere of the overlap that exists between people convicted of crimes, people who have diagnosed “mental disorders” according to DSM and ICD, and the people with whom we work as counsellors and psychotherapists. And this with a partial, but not complete, eye on sexuality as the topic of this module. The problems of confusion, lack of clear knowledge and feelings of uncertainty are caused or exacerbated by the fact that schools and universities teach little or nothing about mental disorders or about the criminal justice system, and neither do most training programmes in counselling and psychotherapy. The end-result is that psychiatrists know their DSM; lawyers know the law and the criminal justice system; forensic psychologists and forensically specialised psychiatrists know a lot about people with psychological problems or mental health problems in prisons – but general psychotherapeutic practitioners rarely know even many basic points.

A good reference as introduction to the issues covered here, but with much more detail, is the British-based and contemporary Vossler et al. (2017).

Let us list a number of situations that most general psychotherapists are unlikely to encounter.

• Working with people while they are in prison is a specialty. It is only done by people who have applied to and been accepted for such positions. The work is usually done under close supervision of an experienced insider with special training and years of experience of forensic work. It cannot be done on an ad hoc basis, as the prison system requires extensive and time-consuming background checks before letting anyone spend time in prison with prisoners. While it is desirable that this work is done, as people in prison have mental health issues at least as much and probably more than the general population, and psychotherapy may help with rehabilitation and with reducing the re-offending rate – it is only for the few, not the many.
• Working with known sex offenders is equally rare and specialised. A few institutions and groups specialise in this work, including the Portman Clinic in London, but this necessary work requires special training, the building up of experience, and specialised supervision. It is not for most psychotherapists and is not the reason to learn more about forensic issues, or the criminal justice system, or about the relationship between mental health problems and committing crimes.

Following are some reasons why it is so important to expand one’s knowledge about crime, mental health and psychotherapy.

• Many or most psychotherapists will sooner or later work with the victims of crime, or at least of threatened crime and / or crimes that have not led to criminal convictions (e.g. think about unsolved assault, harassment and rape cases; and about many or most of the cases of child abuse we hear about and are involved in). It will help, sometimes greatly help, if we have an outline of what is involved in bringing someone to justice and how the criminal justice system works, in the country in which one practises. It is not possible in the context of this module to even scratch the surface of this.
• There are legal and ethical issues involved when we hear in confidence in our therapy room about what our clients have done, what they fantasise about, what they feel urges to do. Some of the ethical issues will be touched on in the section on Ethics below. A main issue is whether there is a legal obligation in some circumstances to break confidentiality, how certain you need to be, and how to go about it if you do. For that, an idea of the difference between the concept of crime and that of mental disorder is important – though it is only a part.
• It is well possible that we will work in our consulting room with clients who have the potential to commit crimes, and who fantasise about that. For fantasies about sexual activity which if enacted would be criminal, Kahr (2007) is a good source that gives representative information about sexual fantasies in the British population. It clearly is very desirable (but not at all easy) to be convinced that nothing in our work makes it more likely that a crime will be committed; and hopefully, we might be working with feelings and fantasies in a way that leaves our clients less distressed, and less likely or not likely at all to act on their fantasies – if they are criminal. In any case, if part of our response to fantasies or urges would be, to be so shocked that we could not bear listening to them, we may well never hear them, in which case none of the above good possibilities even has a chance of realisation. That means being able to listen to unpleasant, distasteful, violent, criminal behaviours, or fantasies about them. This is not an unknown theme, and typically gets a certain coverage in training, but especially in the areas of sexuality, unusual sexual acts, violence, paraphilic disorders, coercion and crime, most people have limits beyond they would find it difficult to go – even with supervision.

Much of the material described in this module, and in the references, would be helpful in the ideal familiarisation of an experienced general psychotherapist. Whether it is themes in dreams, fantasies and images that we are told, or directly material coming up in the countertransference, the more familiar we are with certain human possibilities and desires, the easier it will be to do good work with the client, and the less we will feel overwhelmed or even incapacitated. The different Kinsey reports (1948; 1953), the Hite report (1976) and other overviews of the range of human sexual behaviour can all greatly help.

Clients who have been subject of sexual assault or rape, with or without evident PTSD as a result, are a special group to work with. Not everyone can do this or wants to do it, but it is a very important service to such survivors that there are counsellors and organisations that do. If we do this work, or encounter it without having sought it out, we may need extra supervision, and extra CPD to prepare us for this work. [some references here to be added]

Not many people will work with clients who have definite paedophilic urges, who have not offended and / or have not been caught (and how would we be certain of this?), but who are distressed and have parts that do not want to offend and ask for help. In most cases, unless you feel called to do this work, it may be best to refer these people to counsellors or psychotherapists who have relevant experience and training.

These are categories of sex offenders who are likely to be on the Sex Offenders Register (technically a part of the Violent and Sex Offender Register, kept by the Criminal Records Office, which is managed for the Association of Chief Police Officers in the UK) when they have been convicted, and their prison sentence is spent. They need and deserve psychotherapeutic support. And are not easy to work with. [reference]

DSM-5 devotes a full page at the start of the work to the issues for psychiatrists of the boundary and difference between their work and that of the criminal justice system (DSM-5, 2013:25). Paraphrased, they stress that DSM-5 diagnoses are designed to support clinicians, public health professionals, and researchers, rather than the court system. If the criminal justice system refers to the presence or absence of a mental disorder, a DSM-5 diagnosis can help. Mental health diagnosis can also help in future decision-making (such as about probation), and in risk assessment. However, there are clear limitations, and risks of mental health diagnoses being misused or misunderstood. Standards of competence, of criminal responsibility, and of legal definitions of disability, are not directly envisaged or catered for in the text of DSM-5 or ICD-11. It is rare that the presence or absence of a diagnosis directly informs about a specific level of impairment, disability, or the presence or absence of diminished control over a person’s behaviour. This guidance was written for psychiatrists but is just as relevant for counsellors and psychotherapists.

A key issue that is used in therapy and in the criminal justice system, but that in a way transcends them, is that of consent. This has legal meanings and consequences, which are for lawyers to work with. Consent has consequences for DSM and ICD diagnoses, as it appears in the criteria for a number of the paraphilic disorders, and in the definition of sexual partner or spouse violence.

Consent is also highly central for good sex, as well as for ethical sex. There is a real shortage of good literature about consent – often it is assumed that

• it is ‘evident’ what consent is, or
• it is ok to follow the cultural norm of many countries that you may assume that there is consent if there is no overt distress, or
• if a person does not explicitly say no (and saying a direct verbal no is rare in many cultures, including British culture), you are safe to assume that there is consent.

These assumptions do not constitute a good or even an acceptable basis. Ideas about “informed consent” advocated in Bioethics textbooks (e.g. Beauchamp and Childress, 2013), used by lawyers and in hospitals (again often devised by lawyers), are far too legalistic for most people to be realistic. One of the best practical and yet detailed texts on a higher standard of consent that takes into account relational psychology, is chapter 5 in Barker and Hancock (2017).

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Arlington, VA: American Psychiatric Association.

Barker, M.-J., & Hancock, J. (2017). Enjoy sex (how, when and if you want to): A practical and inclusive guide. London: Icon Books.

Beauchamp, T. L., & Childress, J. F. (2013). Principles of biomedical ethics (7th ed.). New York: Oxford UP.

Hite, S. (1976). The Hite report: A nationwide study of female sexuality. New York: Seven Stories Press.

Kahr, B. (2007). Who’s been sleeping in your head? The secret world of sexual fantasies. New York: Basic Books.

Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. (1948). Sexual behavior in the human male. Philadelphia, PA: W B Saunders.

Kinsey, A. C., Pomeroy, W. B., Martin, C. E., & Gebhard, P. H. (1953). Sexual behavior in the human female. Philadelphia, PA: W B Saunders.

Vossler, A., Havard, C., Pike, G., Barker, M.-J., & Raabe, B. (2017). Mad or bad? A critical approach to counselling and forensic psychology. London: Sage.

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Authored by Henry Strick van Linschoten

Using words, labelling, classifying and diagnosing are essential human activities, as language and verbal expression are an important distinction for us as a species. Although diagnosis is sometimes criticised by psychotherapists from various perspectives, some form of it is needed for many activities, such as doing research, making health decisions, classifying people’s issues statistically to lead to staffing and budgeting decisions. Also, under different headings of “formulation” or “assessment”, in the early process before a person is settled down into seeing a counsellor, there is often an attempt to determine and verbalize what kind of problem a person has, or perceive themselves as having, how severe it is, and what they want to focus on in psychotherapy.

DSM and ICD

There are two dominant systems of classification, designated by their initials as DSM (Diagnostic and Statistical Manual of Mental Disorders) and ICD (## International Statistical Classification of Diseases and Related Health Problems**). DSM is a product of the American Psychiatric Association. Their latest major revision (the first one was published in 1952), DSM-5, was published in 2013. ICD is a classification issued by the World Health Organization (WHO), starting in 1949. ICD has a primary emphasis on its use for coding causes of death, to aid in national and international mortality and morbidity statistics. As such it is a universal standard, also used in the USA – but this aspect of the ICD is less relevant to psychotherapists. The last official ICD edition was ICD-10, endorsed in 1990. A fairly final version of ICD-11 was published on the Internet in 2018. It will be passed for endorsement to the member states of the World Health Assembly in 2019, and is scheduled to go into effect in 2022. The references used here for DSM-5 will be DSM-5 (2013) or DSM-5, and for ICD – ICD-10 (1992), ICD-10 (2016) and ICD-11 (2019). The level of detail in the ICD reference documents is considerably lower than that in DSM – about one third of the length in the case of sexuality.

DSM and ICD are imperfect systems and are much criticised. The reason for their great influence lies in their role in national health systems, for statistics about health, illness and death, or research, and because there is no other existing system that remotely approaches them in terms of acceptance or credibility. Hence, this module will summarise the current categories, as they continue to be the “best we have”.

DSM-5 and ICD-11 deal with sexual issues relevant to this module under a few overall headings. They both refer to “paraphilic disorders”. They have a very similar category called “gender dysphoria” by DSM-5 and “gender incongruence” by ICD-11. A third group of issues is called “sexual dysfunctions” in DSM-5, and divided under two headings, “sexual dysfunctions” and “sexual pain disorders” in ICD-11. ICD-11, with its greater general medical emphasis than DSM, also describe “changes in female genital anatomy” and “changes in male genital anatomy”. This section will mostly follow the DSM terminology and headings, and only refer to ICD-11 when there are significant differences.

The major categories recognised by DSM-5 are sexual dysfunctions, gender dysphoria and paraphilic disorders.

Sexual dysfunctions

The sexual dysfunctions listed are:

• Delayed ejaculation
• Erectile disorder
• Female orgasmic disorder [i.e. not enough; insufficiently intense]
• Female sexual interest / arousal disorder [absent or reduced; combining the previously separate sexual arousal and sexual desire disorders]
• Genito-pelvic pain / penetration disorder [This diagnosis merges the earlier diagnoses of vaginismus and dyspareunia, largely because they were difficult to distinguish clearly]
• Male hypoactive sexual desire disorder
• Premature (early) ejaculation
• Substance/medication-induced sexual dysfunction

DSM is somewhat more organised into separate male and female categories than ICD-11. They have in common the continued “official” emphasis diagnostically on normative-ideal categories. Ejaculation can be premature or delayed. Female orgasms and erections can be “disordered”. Sexual interest, arousal and desire (ICD) can be too low (but it is noteworthy that there is no diagnosis for it being considered too high).

A particular point worthy of note is that the formulation for the broadly equivalent “female sexual interest / arousal disorder” and “male hypoactive sexual desire disorder” is markedly different. This is maintained in the detailed diagnostic criteria used for men and women (and note the binary character of this distinction here), which are more precisely normative for women, where the criteria require investigation of initiation of sexual activity, sexual excitement / pleasure, and genital or nongenital sensations during sexual activity…

Norms

This leaves open the question where these norms have their origin. Is it genuinely internal, based on what the persons concerned feel and experience themselves? Or are the norms responding to, or have they internalised, judgements coming from society, culture, religion, the media, family, parents, the community, as to what is “normal” and “satisfactory” functioning, and what is “abnormal”, “wrong”, “problematic”? Other sections will say more about this, but the general trend of the past decades among sex educators, sexologists and most sex therapists has been to abandon such normative views as much as possible. Judgements about what is wrong and abnormal were also behind the condemnation as “abnormal”, “pathological” and criminal of homosexuality, and of wishes for gender transition / affirmation, leading to attempts at “conversion therapy”, lending support to stigmatisation, elevated rates of suicide and being subject to attacks, assault and homicide (Kleinplatz, 2012).

A main line of defence against the questioning from the designers of the classification systems is that they only recognise statistical anomalies as disorders when the general condition is fulfilled that the symptoms must cause “clinically significant distress in the individual, or disability in social, occupational or other important activities”. In the introductory passage on the general distress criterion, DSM-5 states that “socially deviant behavior (e.g., political, religious or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflicts results from a dysfunction in the individual [i.e. the distress or disability referred to above].” These distinctions and qualifications need to be kept permanently in mind, the more so for anyone who gets involved in debating, influencing or making decisions about the diagnostic categories used in DSM and ICD.

Further qualifications made in the text of DSM-5 are helpful in making sense of sexual problems and of what can be regarded as a form of mental disorder. DSM-5 stresses that most of the “sexual dysfunctions” listed can also be caused by “nonsexual mental disorders”, by severe relationship distress or other significant stressors, be the effect of substance use or medication, or be due to another medical condition. If any of these reasons obtain, it is incorrect to maintain the sexual dysfunction as a diagnosable disorder in itself. In the introduction to the whole chapter, it is explained that sexual difficulties can be the result of “inadequate stimulation”, possibly caused by “lack of knowledge”. And for most disorders it is specifically reiterated that assessment must take the “interpersonal context” into account.

Finally, users of the categories are urged to consider that sexual response is usually “experienced in an intrapersonal, interpersonal and cultural context”, with biological, sociocultural and psychological factors interacting. They specifically mention “severe relationship distress” and “partner violence” as factors that may lead to a decision not to make a diagnosis of sexual dysfunction.

Gender dysphoria

Another important sexuality-related category is that of gender dysphoria (DSM-5) or gender incongruence (ICD-11). As explained in the introduction, this module will only briefly deal with this. The new formulations in DSM-5 and ICD-11 are different but similar. They both make a distinction whether the condition concerns a child, or on the other hand an adolescent or adult. ICD-11 uses the formulation: “Gender incongruence is characterized by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex. Gender variant behaviour and preferences alone are not a basis for assigning the diagnoses in this group.” DSM-5 also has the word incongruence in this central position, but uses “assigned gender” instead of “assigned sex”.

Paraphilic disorders and paraphilias

ICD-11 has two different higher-level categories. Under “conditions related to sexual health” they classify “sexual dysfunctions”, “sexual pain disorders” and “gender incongruence”. Note that the keyword here is “conditions”, not “disorders”. “Paraphilic disorders” are classified under the heading of “conditions related to sexual health”, as well as the heading of “mental, behavioural or neurodevelopmental disorders”.

The DSM classified a particular group of sexual behaviours and activities as “sexual deviations” until 1979; DSM-III from 1980 onwards, and the later editions, use “paraphilias”. This replaces the time-honoured psychoanalytic term of “perversions”, used by Freud as well as Lacan – although it goes back to French psychiatrists at least in 1885 (Valentin Magnan) and probably earlier. The term “perversions”, from its earliest uses on in the 19th century, was not a neutral diagnosis, but a form of condemnation – it included a judgement. In contemporary sexological thinking, many sexual behaviours that used to be called perversions or paraphilias are now recognised as statistically much less “abnormal” than before, but also, as long as they are fully (affirmatively, enthusiastically) consensual, and do not do any lasting damage, are seen as a legitimate use of human freedom to live varied and differentiated lives, accept one’s identity, or choose one’s lifestyle. DSM-5, in what many regard as a significant change, has broken new ground by making a distinction between paraphilias and paraphilic disorders.

DSM-5 defines a paraphilia as “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners.” It will be clear, and has been fully documented in the Kinsey reports (1948; 1953), that this covers a great deal of sexual activity – probably even masturbation on a natural reading of the wording. They add that the qualification “intense” can not always be maintained, and the definition would really extend to any “preferential” sexual interest.

Against this, the same activities covered by this wide definition of paraphilia, turn into a “paraphilic disorder” if its satisfaction entails personal harm or risk of harm to others, or if the “sexual urges or fantasies cause clinically significant distress or impairment in social, occupational or other important areas of functioning.” Harm is automatically assumed if the individual “has acted on the sexual urges with a non-consenting person” (or, in the case of pedophilia, has acted on their urges at all). DSM-5 adds that “a paraphilia by itself does not necessarily justify or require clinical intervention” – only a paraphilic disorder does.

DSM-5 divides the paraphilias into two main groups – based on anomalous activity preferences (e.g. voyeurism; inflicting pain), and based on anomalous target preferences (e.g. fetishes).

ICD-11 has decided on a somewhat different wording, where they add, after the general definition of paraphilic disorders, that “paraphilic disorders may include arousal patterns involving solitary behaviours or consenting individuals only when these are associated with marked distress that is not simply a result of rejection or feared rejection of the arousal pattern by others or with significant risk of injury or death.”

Non-sexual sadism and masochism do not feature in these definitions, nor is there elsewhere a category for violence, or anything indicating that violence can be a disorder. It is clear that it is assumed in DSM-5 that there are substantial areas of human action, especially involving violence, which may be legally regarded as crimes, but which do not involve the conclusion that the acting person has a (diagnosable) mental disorder.

DSM-5 lists the following paraphilic disorders:

• Voyeuristic disorder
• Exhibitionistic disorder
• Frotteuristic disorder [always with a nonconsenting person]
• Sexual masochism disorder
• Sexual sadism disorder
• Pedophilic disorder
• Fetishistic disorder
• Transvestic disorder
• Other and unspecified paraphilic disorders

For voyeurism, exhibitionism, frotteurism and sexual sadism, the text of the detailed criteria makes clear that acting on these tendencies with consenting persons, and without the acting person being significantly distressed or impaired, do not fulfil the criteria, and cannot be classified as paraphilic disorders – they are paraphilias, but not mental disorders, in the newly created terminology of DSM-5.

The definition of paedophilia concerns fantasies, sexual urges or behaviours involving sexual activity with a prepubescent child or children, and only when the person diagnosed, the person committing the acts, is at least 16 years old and is at least 5 years older. Many other definitions and variants are possible and were considered in the committees. Some of these other versions are closer to legal definitions of non-consensual sex, or any sex with minors. Another proposal that has been advocated is the distinction between ephebophilia – sexual interest by an adult in 15-19 year-old children, hebephilia – interest in pubescent children younger than 15, and paedophilia – sexual interest in prepubescent children. With a basic assumption that there would or might be significant differences between the people with these three diagnoses. None of these ideas were maintained in the final version of DSM-5.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Arlington, VA: American Psychiatric Association.

Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. (1948). Sexual behavior in the human male. Philadelphia, PA: W B Saunders.

Kinsey, A. C., Pomeroy, W. B., Martin, C. E., & Gebhard, P. H. (1953). Sexual behavior in the human female. Philadelphia, PA: W B Saunders.

Kleinplatz, P. J. (2012). Is that all there is? A new critique of the goals of sex therapy. In P. J. Kleinplatz (Ed.), New directions in sex therapy: Innovations and alternatives (pp. 101–118). New York: Routledge.

World Health Organization. (1992). ICD-10 : The ICD-10 classification of mental and behavioural disorders : Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization.

World Health Organization. (2016). ICD-10 online. Retrieved from https://icd.who.int/browse10/2016/en

World Health Organization. (2019). ICD-11 online. Retrieved from https://icd.who.int/browse11/l-m/en

The post Terminology, diagnosis and labeling appeared first on Confer.

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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