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Years ago, I saw a cartoon that really made me laugh: In a therapist’s office, a woman is lying on the typical Freudian couch, and says to the therapist, “You know, doctor, there are some things I don’t tell you.”

And the therapist responds, “I want you to know, Mrs. Jones, that I really appreciate that!”

Like most of the best jokes, it hits on a deep truth that we rarely acknowledge—we don’t know what we don’t know, and maybe don’t even want to know.

As a trained sex therapist, I give talks to groups of other therapists around the country, and I often ask for a show of hands of those who have had any kind of sex-therapy training, even a one-day workshop. In a roomful of 50 or 60 therapists, I usually get no more than a half-dozen hands. If I give a talk on problematic sexual behaviors, marital therapy, or sexual abuse, I fill a room. If I offer a talk on helping individuals and couples with sexual pleasure, less than half as many people will show up.

Is it not striking that in a profession seeking to help people in their relationships and personal struggles, that such a fundamental element as sexual intimacy is either avoided or not deeply studied by therapists? During therapy, when sexual issues arise, even those of us who have had any sex-therapy training will often fall back on their training about sexual trauma, sexual abuse, and problematic sexual behaviors, seeking out these dark pathologies in order to deal with them.

“I used to be one of you,” I tell attendees. “I was a long-time therapist, and went down this very path until I discovered research and clinical training on healthy sex, and realized without a single day of training in this how wrong I had been in my approach to my clients.”

Once I sought out sex therapy training, I came to understand such an oversight as egregious, a disservice to my clients, and even unethical. This doesn’t mean that I still don’t, today, examine possible trauma-driven and pathological reasons for why a client comes to my office who is sexually suffering. It does mean, however, that I also have tools on how to look at their issues with informed healthy sex and sexuality information.

Couples are coming to us with problems in their relationship, but they usually have problems in their sexual side of their relationship, as well, and we are not trained to deal effectively with these. There needs to be two separate, parallel conversations, one about relationships and the other about sexual health. Many people think that if the relationship gets better, then the sex will get better as well, or vice versa. That’s a myth.

Too often, the untrained therapist will default to their own judgments about what constitutes a healthy sex life—perhaps based their own sexual history of abuse or trauma or infidelity, project this onto the clients—and then lead the individual or couple accordingly, often taking sides with the person who feels aggrieved in the relationship. We are quick to find sexual pathology, but we have an aversion to dealing with sexual pleasure. This is not helpful.

What about pleasure and fun in this most universal of human activities? When we begin to study healthy sex, we are suddenly presented with myriad worlds of sexual desires and practices, many of which are considered taboo by the culture in which we live, and yet are quite normal, even healthy, for a particular client and couple. While before we may have been successful helping someone deal with sexual abuse issues, we have not helped the individual or couple into a conversation about sexual health including sexual pleasure, or their sexual differences.

Let me offer some examples:

The Porn Couple

A couple comes in that has been married for 30 years, reporting that they have enjoyed a pretty good sex life—several times a week, changed it up over the years, etc.—and then she finds his porn and suddenly is outraged, labels him a “sex addict,” while comparing herself to the images he’s looking at (mostly younger and slimmer women). Now her discovery has negatively affected their sex life, even though everything was fine until she found the porn. The untrained therapist will often side with her, asking him why he needs this, and asking “Isn’t she enough?”

The Sexually Informed Therapeutic Response: The real answer to that is, “Nobody is enough!” Even women are watching or reading things, imagining themselves with some hunky actor or character in a romance novel. Also, what is often true is that the couple never talked about watching porn before so there is a lack of any agreement or conversation about what is okay or not in their relationship. An untrained therapist may get into the trap of good porn/bad porn, and then they have jumped into the couple’s power struggle instead of helping them work out the sexual differences. This marriage had no problem before because he was enjoying both his wife and the porn until the wife took it personally (and maybe the therapist, too), making it about her while it had nothing to do with her. A trained sex therapist would know that.

The therapist must help the couple have a conversation about sexual differentiation—how what we like may not match up, how what we think about in our private moments are ours alone, how I can differ from what you enjoy sexually, and I don’t have to collapse into what you like. Nor do I need to make you lose what you like, but we can find common ground through sometimes difficult and painful conversations.

The Sexually Fluid Partner

Another couple comes in, the partner troubled about having discovered the man watching gay porn. The well-intended therapist may immediately conclude that this client is gay or bisexual, without the training to understand the nuances of sexual fluidity.

The Sexually Informed Therapeutic Response: In facilitating the conversation, the wife comes to realize that he has always had this fascination, and until now it didn’t affect their sex life. He is often not gay nor even bisexual but simply a straight man who enjoys gay porn. There is research that has shown that 20 percent of straight men watch gay porn and 55 percent of gay men watch straight porn1. This doesn’t represent orientation it represents variation in erotic interest and sexual fluidity.

The Affair Couple

A man discovers his wife has had multiple affairs, calls her a liar, a cheater, puts her down for her unwillingness to keep the marital contract. The therapist would typically begin looking at a history of sexual abuse, or whether she had an attachment disorder, looking for the negative pathologies only.

The Sexually Informed Therapeutic Response: Considering we live in a monoga-normative culture which insists on only one partner a sex therapist would also considering a positive, strength-based approach, and ask, “Maybe you don’t want monogamy,” helping her get clear around that. She might look at her choices around wanting an open relationship or even being polyamorous. This doesn’t mean it will go in any one direction but it does mean that there is a balance of healthy and unhealthy interventions.

The Kinky Couple

A couple is involved in consensual kinky behavior—tying down, choking, spanking, spitting on the partner, slapping, etc.—and enjoy it. The untrained therapist would become worried that they were reenacting early trauma and that something was wrong with them.

The Sexually Informed Therapeutic Response: While this is important to sort out, this couple may say that even if it is reenacting early trauma, they enjoy it. This may not feel good to the untrained therapist who doesn’t know how to look at it through a sexual-health lens. But if he is trained in healthy sex therapy, then the conversation becomes “Is it safe?” Is it mutual and consensual?” Are they having open and honest communication around the behaviors?

I highly recommend therapists seek out as many sexual-health educational trainings and workshops as possible; go to the conferences of and join sex-related organizations such as SSTAR (Society for Sex Therapy and Research), AASECT (American Association of Sex Educators, Counselors, and Therapists), SSSS (Society for the Scientific Study of Sexuality), and/or ISSWSH (International Society for the Study of Women’s Sexual Health); and read sex research and therapy related journals to keep up on current research in the field.

Your practice will become far more effective when you do. 

References

1. Sexually Explicit Media Use by Sexual Identity: A Comparative Analysis of Gay, Bisexual, and Heterosexual Men in the United States, by Downing, M.J., Schrimshaw, E.W., Scheinmann, R. et al.

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