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Sex

What Shrinks Don't Know About Sex

One of the main weaknesses of American psychotherapy is the area of sexuality.

Key points

  • Patients would be better served if therapists has more training in sexuality.
  • When therapists don't know as much about sexuality as they need to, what do they typically do?

Psychotherapy involves a wonderful set of tools. Every year, skillful therapists save marriages, facilitate divorces, educate parents, ease trauma, and help people overcome depression or anxiety, sometimes providing a link between patients and psychiatrists.

But one of American psychotherapy’s main weaknesses is the area of sexuality.

Most therapists get very little training in human sexuality—often as little as 10 hours. The focus is often on child molestation and sexual violence, on the one hand, and sexual orientation and gender identity, on the other.

What’s missing? Frequently, such mundane issues as the sexual side effects of common medications; contraception; why many women can’t orgasm with a partner; how Viagra works; just how common masturbation is; and the truly ambiguous nature of sexual exploration, hooking up, seduction, desire, and teasing. The world may be focused on #MeToo, but in real life, “no” doesn’t always mean “no”—just as “yes” doesn’t always mean “yes.”

Without specific training in day-to-day sexuality, most therapists have to fall back on their personal experience and cultural norms. The former is always limited and frequently negative, while the latter are typically shame-centered, culturally slanted, and frequently negative.

Here are some notes about what psychotherapy could do way better regarding sexuality.

Porn addiction” and “sex addiction

These dangerous concepts are considered mainstream by therapists who may have limited knowledge about sex. Clients who use a lot of porn (almost entirely men) or go to sex workers (ditto) are often considered “addicts” who need to be in life-long “recovery.”

Most therapists don’t have a model of porn use or visiting sex workers that imagines a guy making a rational choice or loving his partner. And when a woman busts a guy for watching porn, most therapists don’t talk about why she finds his porn watching so upsetting or the fact that they didn’t have a no-porn agreement when they coupled up. Rather, the question is typically “How do we get the guy to stop this disgusting habit?”

Infidelity

The typical therapist sees infidelity as involving a selfish betrayer and a victimized betrayed. There’s rarely much discussion of the betrayed’s contribution to the relationship—especially if it’s a woman who has gradually withdrawn from her mate sexually.

Unfortunately, most therapists handle infidelity by supporting radical power imbalances—from unlimited (yes, unlimited) discussions of “how could you do this to me” to giving control of the betrayer’s phone and laptop to the betrayed. This kind of control does not build trust—it never satisfies the betrayed and only creates distance with the betrayer.

Worse is the new fad of “formal therapeutic disclosure.” This is where the betrayer (often identified as a sex addict, if it’s a male) is required to tell his partner every feature of his unauthorized sexual behavior—how many times, how many minutes, how many orgasms, which positions, what color lingerie, and more. The process is labelled as part of healing, but it simply gives the betrayed a jillion details to obsess about, preventing real peace or reconciliation.

The “meaning” of sexual fantasies

Almost everyone has fantasies that they don’t act out: leaving your family and starting a new life in Paris; embezzling money and paying off your house; finally telling off that bossy sister-in-law; eating all the chocolate in the entire world, just to name a few.

Most people know such fantasies are not dangerous and that they have no predictive value. Most people don’t avoid driving past a bank because they fantasize about robbing a bank.

Unfortunately, many people lose that common understanding when the fantasy is sexual—and too many therapists do, too. So patients wracked with guilt or fear about their fantasies (“Does that mean I’m gay?” “Does this mean I’m a child molester?” “Am I doomed to be unfaithful?”) don’t get the friendly reassurance they need. Instead, some therapists want to decipher what a sexual fantasy “means” or try to change it to something more “normal.”

Unless they are totally obsessive, sexual fantasies have no meaning. No, you don’t “really” want to have sex with Lassie. Avoid a therapist who tries to make your sexual fantasy more “normal,” more “ethical,” or less “patriarchal.”

~Sexual orientation"

Today’s therapists are making the whole sexual orientation issue so complicated—it’s now the tail wagging the dog. “Asexual? “Demisexual?” “Graysexual?” The definitions of the now dozens of orientations are virtually indistinguishable from what used to be called “preference,” “ambivalence,” and even “I’m not sure.”

We don’t need a special word for people who lack interest in sex (no ex-husband jokes here, please) or are turned on only when they feel emotional connection, or like a bit of risk-taking with their sex. These are just common configurations of the wide range of human sexualities.

Why does it matter? As a therapist, I know that categories typically end conversations. When we ask why a patient decided something and their answer is “I’m conflict-avoidant" (or cupioromantic, or whatever)—they're not actually investigating how they feel, what they want, and what they were trying to accomplish. You know—who they are, not what they are.

Therapists strive to be understanding and accepting. That’s fine—as long as we keep encouraging people to investigate themselves, rather than accept shortcuts that require little thought and mean nothing.

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