Sexuality Counseling & Therapy

1. Sexuality Counseling & Therapy Foundations for Practice

2. 2012 AAMFT Conference, Charlotte, North CarolinaThursday, September 13, 2012 Stephen Southern Dawn Ellison & Kate Hilton Mississippi College

3. For additional information: Stephen Southern361-876-2030stephensouthern@msn.com The material included in this professional presentation does not present the views or positions of Mississippi College.

4. How I love all of you! Do you feel me wrap you Up with myself and my warmth, like a flame round the wick? …I spread over you! How lovely your round head, your arms, Your breasts, your knees and feet! I feel that we Are a bonfire of oneness, me flame flung leaping round you, You the core of the fire, crept into me. D.H. Lawrence, Wedlock

5. The Journey of a Sex Therapist • Behavior Therapy versus Psychoanalysis • Masters & Johnson Institute • American Association of Sexuality Educators, Counselors & Therapists (AASECT) • Whither Sex Education • Sexy Seniors • Sexual Medicine Institute • The Man Who Feared His Buttons • The Couple and Their Homework • Perversion, Paraphila & Sexual Addiction • Penile Plethysmography • Trauma-Based Disorders • Cybersex Addiction: The New Tea Room • Viagra Defeats Sex Therapy • The “New View” Rediscovers Intimacy

6. Sexy Seniors: He’s coming home …He’s coming. He’s coming home for lunch. I hear his footsteps on the porch. I cooked him his favorite meal…I remember the smell of the orange blossoms…He’s coming in the door. He sees me and smiles. That dog, he’s got something besides lunch on his mind. He comes up and hugs me. He kisses my neck. I can smell his honest sweat. He was a good, hard working man (coming home for lunch from the orange grove where he worked).

7. History • 1900 • Freud viewed sexual problems as symptoms of neuroses • Iwan Bloch proposed the new field of sexology • 1920s • Havelock Ellis wrote extensively about sexuality, worked with homosexuals (addressing sexual inversion), and taught women non-demand pleasuring • Magnus Hirshfeld founded sexual science institute, teaching sex education and contraception. Hitler converted his center to Health & Racial Hygiene Bureau • 1930s • Paul Popenoe taught marriage enrichment, including sexual topics, in Los Angeles • Lester Dearborn, a Boston gynecologist, sketched the anatomy of his patients, used test tube device to observe penetration and simulation of intercourse, pioneered sexual history taking, and founded the American Association of Marriage Counselors • 1940s • Alfred Kinsey advanced knowledge about wide range of sexual behavior through sexual history, interview, correspondence, pornography, and self-exploration • 1950s-1970s • William H. Masters pioneered hormone replacement therapy and established research program in human sexual functioning. He monitored in the laboratory physiological changes during masturbation and intercourse. Later, developed with Virginia Johnson sex therapy.

8. History • 1970s • Joseph LoPiccolo and other behavior therapists applied principles of counterconditioning to sex therapy techniques • Helen Kaplan integrated sex therapy and medical practice • 1980s • Proliferation of sex therapy techniques and laboratory-based treatment of sexual dysfunction and deviance • Mark F. Schwartz expanded the work of Masters & Johnson Institute to address wide range of intimacy dysfunction and trauma-based disorders • Alan Bell redefined and de-pathologized homosexuality • Sandra Leiblum and others addressed women’s sexual rights and potentials • 1990s • Proliferation of self help approaches and non-Western sexual disciplines (e.g., Kundalini yoga and Kama Sutra) • Ray Rosen, Barry McCarthy and others integrated sexual and relational therapies • David Schnarch integrated sex/marital and objects relations therapies • “Viagra killed sex therapy” • 2000 and beyond • Direct marketing of men’s sexual rehabilitation services • Lenore Tiefer and others reclaim women’s sexuality in the New View

9. Relevant Developments in Sexual Health in the Past 25 Years (Pan American Health Organization, Antigua, Guatemala, May 19-2000) • Advances in knowledge about different aspects of human sexuality. • The emergence of the HIV pandemic and increased awareness of the impact of other sexually transmitted infections. • Formation of a solid body of knowledge originated in the writings and views of feminist scholars. • Definition and consolidation of the field of reproductive health. • Recognition of violence, including sexual violence, especially against women, children and sexual minorities, as a serious public health issue. • Recognition of sexual rights as human rights. • Increased advocacy by social movements for recognition, respect and the protection of rights of “minorities” (such as gay, lesbian, and transgender individuals) • Development of effective and safe medications to modify and improve sexual functioning of individuals.

10. The Beginning • “Sex is a natural function” (Masters & Johnson, 1966, 1970) • In sexuality, we find the life energy (eros) associated with all bonding or attachment. • Each individual will discover his or her capacity for sexual intimacy as roadblocks are removed

11. Promises & Pitfalls of Pair Bonding

12. Intimacy • Characterized by the capacity for emotional and physical closeness in various domains in life • Begins with the capacity for good object relations in childhood • Elaborated by healthy (nutritious) life experiences • Expressed between open and honest partners in a committed relationship

13. Express love verbally on a daily basis Physically affectionate: hugging, kissing, touching Express love sexually within an exclusive, committed relationship Express admiration for one another in private and social settings Engage in mutual self-disclosure: sharing thoughts, feelings, hopes, and dreams Permit one another to be autonomous and active in the world outside the relationship Encourage self-awareness and self-discovery for each person Offer to each other an emotional support system and respite from the demands of daily life Express love materially by giving gifts and sharing the work and rewards of the relationship Accept demands and tolerate shortcomings, giving unconditional positive regard with a minimum of expectations and projections Create time to be alone together to practice the relationship without distraction or intrusion Share a reason or purpose in staying together, identifying a mission for the relationship Characteristics of an Intimate Couple

14. Sexuality Sexuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles, and relationships…Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious, and spiritual factors. World Health Organization conference on sexual health, January 2002.

15. Life Behaviors of a Sexually Healthy Adult (SIECUS) • Appreciate one’s own body • Affirms that sexual development may or may not include reproduction or genital sexual experience • Interact with both genders in respectful and appropriate ways • Affirm one’s own sexual orientation and respect the sexual orientation of others • Express love and intimacy in appropriate ways • Develop and maintain meaningful relationships • Avoid exploitative and manipulative relationships • Make informed choices about family options and lifestyles • Exhibit skills that enhance personal relationships • Discriminate between life enhancing sexual behaviors and those that are harmful to self and/or others • Express one’s sexuality while respecting the sexual rights of others • Express one’s sexuality in ways congruent with one’s values

16. Bonding

17. Roadblocks to Intimacy • Life trauma, especially physical and sexual abuse • Sex negative environments • Lack of accurate sex and relationship information • Lack of experience • Punishment for sexual exploration • Shame associated with closeness

18. Intimacy Dysfunction • Addiction • Mental illness and emotional disturbance • Neurotic pair bonding • Isolation and avoidance • Personality disorder • Relational boundary disturbance • Sexual dysfunction and dissatisfaction • Paraphilia and perversion

19. Sexual Dysfunction: A Neglected Public Health Problem • Approximately 50% of couples and 50% of individuals experience sexual dysfunction during the lifespan (Masters & Johnson, 1970) • Among U.S. adults, aged 18-59, 43% of women and 31% of men experienced sexual dysfunction in the last 12 months (Laumann, Paik, & Rosen, 1999) • Summarizing the results of several studies,10-52% of males and 25-63% of women in the general population may experience sexual problems at any given time (Heiman, 2002) • A recent study (Clayton, Keller, & McGarvey, 2006) reported that 95.6% of women and 97.9% of men taking SSRIs exhibited impairment in at least one phase of sexual functioning • Generally, sexual dysfunction rates increase with chronic illness, including diabetes and cardiovascular disease (Jackson, Rosen, Kloner, & Kostis, 2006; Hayes & Dennerstein, 2005; West, Vinikoor, & Zolnoun, 2004) • Sexual dysfunction lowers the quality of life and increases risk of depression (Feldman et al., 1994; McCabe, 1997)

20. Table 1 Types of Dysfunction by Sexual Response Cycle Phase ________________________________________________________________ Type of Dysfunction Phase Male Female ________________________________________________________________ Desire Hypoactive Sexual Desire Hypoactive Sexual Desire Sexual Aversion Sexual Aversion Sexual Desire Discrepancy Sexual Desire Discrepancy Sexual Compulsion Sexual Compulsion Paraphilia Paraphilia Arousal Erectile Dysfunction Sexual Arousal Disorder Orgasm Delayed Ejaculation Anorgasmia Rapid Ejaculation Resolution Pain Pain Sexual Compulsion Sexual Compulsion Sexual Dissatisfaction Sexual Dissatisfaction ________________________________________________________________ Common or typical presenting problems are highlighted in boldface.

21. Paraphilias • Exhibitionism • Voyeurism • Frotteurism • Fetishism • Transvestism • Sexual masochism • Sexual sadism • Pedophilia

22. Compulsive Sexual Behavior • Cruising and preoccupation • Multiple partners • Anonymous partners • Fixation on unattainable partner • Compulsive masturbation or autoeroticism • Compulsive extramarital affairs • Compulsive cybersex

23. Compulsive Cybersex • More than half of Americans (172 million persons) regularly use the Internet with as many as one third going online for sexual purposes (Cooper, 2004) • 60 percent of all visits and commerce on the Internet were associated with sexual activities (Schneider & Weiss, 2001) • Internet sex was the third largest economic sector on the Web generating annually one billion dollars of revenue (Carnes, Delmonico, & Griffin, 2001) • Cooper (1997) observed that the sexual revolution of the Internet was fueled by the “Triple A Engine” of accessibility, affordability, and anonymity • Problematic cybersex has been associated with heavy Internet use (20 or more hours online per week) (Cooper, Scherer, Boies, & Gordon, 1999). • Schwartz and Southern (2000) described compulsive cybersex as the “new tea room” in which cruising can lead to easy anonymous, impersonal sex. • Treatment of compulsive cybersex involves individual, couple, and group counseling with particular components to address the functions of the addictive behavior pattern

24. Sexual Desire Discrepancies in Couples: A Common Concern in Marital Therapy

25. Sexual Desire • Interest • Motivation • Appetite

26. Cues for Sexual Desire • Emotional bonding • Visual/proximity prompts • Self observation • Implicit romantic scripts • Erotic and explicit dimensions • Linear versus cyclical processes

27. Mutual vulnerability Closeness and intimacy Spirituality Sensual awareness Romantic love Boundary disturbance Dominance and power Anger and aggression Displacement, omission and substitution Objectification Sources of Sexual Desire

28. Varieties of Sexual Desire • Asexuality or celibacy • Hypoactive sexual desire • Hyperactive sexual desire • Balanced or attuned sexual desire • Discrepant sexual desire

29. Hypoactive Sexual Desire • Relatively common in women (20-45%) • Poorly defined • Multiple causation • Persistent or recurring deficiency of sexual fantasies, thoughts, and receptivity to sexual outlet • Personal distress or relationship difficulty resulting from absolute or relative avoidance

30. Causes of Hyperactive Sexual Desire • History of sexual or physical abuse • Sex negative parenting • Sexual shame or guilt • Variant sexual preference • Cognitive, emotional or behavioral dissociations • Depression and anxiety • Lifestyle disorders (e.g., addiction) • Pornography • Relationship discord and dissatisfaction

31. Sexual Desire Discrepancies • Intrinsically relational in nature • Greater the discrepancy, less sexual satisfaction in men and women • Greater the discrepancy, lower level of relationship satisfaction in women • Men’s perceptions of relationship adjustment affected by his estimation of desire discrepancy

32. Gender Issues & Desire Discrepancies • Adult levels of sexual desire influenced by parenting and family of origin issues • Desire discrepancies fueled by problems with identification and Oedipal conflicts • Socialization process in gender roles and persistence of double standard • Gender roles associated with proception in men and acception in women • Putative biological differences and evolutionary imperatives

33. Gender Polarization • Short-term mating (masculine) versus long-term partnership (femininity) • Sexual desire decreases over time with women (not in men generally) • Desire for tenderness increases in women and decreases in men • Sexual satisfaction tends to decline in both • Interest in sexual variety increases, especially in men

34. Men are visual in sexual information processing Men are less affected by relational variables Men tend to be affected by erotic cues Men are motivated to initiate sexual outlet Men perceive linear progression Men have beliefs and distortions that increase sexual participation Women are somatic and kinesthetic in sexual information processing Women are more affected by relational variables Women tend to miss or diminish erotic cues Women are motivated to be passive or receptive Women perceive a cycle in sexual interest Women have beliefs and distortions that diminish sexual participation Gender Differences

35. The New View of Women’s Sexual Desire • Alternative to emerging biomedical model that is grounded in patriarchy and privilege • Rejection of male model as standard for examining desire issues • Rejection of medicalization of sexual concerns • Avoidance of biological reductionism • Willingness to explore politics of sex

36. New View • I. Sexual Problems Due to Socio-Cultural, Political, or Economic Factors. (20% of problems according to Nicholls, 2008) • A. Ignorance and anxiety due to inadequate sex education, lack of access to health services, or other social constraints • B. Sexual avoidance or distress due to perceived inability to meet cultural norms regarding correct or ideal sexuality • C. Inhibitions due to conflict between the sexual norms of one’s subculture or culture of origin and those of the dominant culture • D. Lack of interest, fatigue, or lack of time due to family or work obligations • II. Sexual Problems Relating to Partner or Relationship (65% of problems) • A. Inhibition, avoidance, or distress arising from betrayal, dislike, or fear of partner, partner’s abuse or couple’s unequal power, or arising from partner’s negative patterns of communication • B. Discrepancies in desire for sexual activity or in preferences for various sexual activities • C. Ignorance or inhibition about communicating preferences or initiating, pacing, or shaping sexual activities • D. Loss of sexual interest and reciprocity as a result of conflicts over commonplace issues such as money, schedules, or relatives, or resulting from traumatic experiences, e.g., infertility or the death of a child • E. Inhibitions in arousal or spontaneity due to partner’s health status

37. New View • III. Sexual Problems Due to Psychological Factors (8% of problems) • A. Sexual aversion, mistrust, or inhibition of sexual pleasure due to past…abuse, general personality problems with attachment, rejection, co- • operation, or entitlement • B. Sexual inhibition due to fear of sexual acts or of their possible consequences, e.g., pain during intercourse, pregnancy, sexually transmitted disease, loss of partner, loss of reputation • IV. Sexual Problems Due to Medical Factors (7% of problems) • A. Numerous local or systemic medical conditions affecting neurological, neurovascular, circulatory, endocrine, or other systems of the body • B. Pregnancy, sexually transmitted diseases, or other sex-related conditions • C. Side effects of many drugs, medications, or medical treatments • D. Iatrogenic conditions • (Working Group on a New View of Women’s Sexual Problems in Tiefer, 2004, pp. 254-256; Available: http://newviewcampaign.org/manifesto.asp)

38. Couple Issues &Sexual Desire • Sexual satisfaction accounts for 15-20% of pair bond • Lack of sexual satisfaction associated with 50-75% of relational discord • Sexual dissatisfaction associated with diminished sexual desire, avoidance, and relationship erosion • Relationship satisfaction associated with increased desire and outlet

39. Contradictions in Sexual Desire • Romantic love and sexual desire not always linked • Intimacy and sexual desire can be negatively related • Relationship erosion introduces desire for novel activities and new partners • Long term relationships introduce more demands for adjustment (work and family) • Health issues and aging complicate sexual expression • Sexual desire is a balancing act

40. Treatment of Sexual Desire Issues • Relational • Psychological • Hormonal • Psychopharmacological

41. Goals of Treatment • Expand sexual scripts or schemas to tolerate change and embrace innovation • Advance sexual desire resilience (positive anticipation, pleasure orientation, appreciation of cycle) • Play (leisure, love play, sex play) • Exploration of sexual fantasies and preferences • Expression of desires

42. Peace

43. Sexual and Relational Healing • Premarital counseling • Couples counseling • Object relations therapy • Trauma resolution therapy • Bodywork • Spiritual recovery • Sexual counseling and therapy

44. What is sexual health? “Sexual health is the integration of the somatic, emotional, intellectual, and social aspects of sexual well-being, in ways that are positively enriching and that enhance personality, communication, and love” World Health Organization in Firestone, Firestone & Catlett (2006, p.11)

45. Life Behaviors of a Sexually Healthy Adult (SIECUS) • Appreciate one’s own body • Affirms that sexual development may or may not include reproduction or genital sexual experience • Interact with both genders in respectful and appropriate ways • Affirm one’s own sexual orientation and respect the sexual orientation of others • Express love and intimacy in appropriate ways • Develop and maintain meaningful relationships • Avoid exploitative and manipulative relationships • Make informed choices about family options and lifestyles • Exhibit skills that enhance personal relationships • Discriminate between life enhancing sexual behaviors and those that are harmful to self and/or others • Express one’s sexuality while respecting the sexual rights of others • Express one’s sexuality in ways congruent with one’s values

46. Finding Healthy Sexuality • The Manley (1999) model of positive sexuality includes five dimensions • Spirituality: the core of sexuality; rejecting sexual shame and affirming that sex is good • Personhood: the development of autonomy; accepting one’s sexual self and respecting boundaries • Roles & Relationships: the expression of trust, vulnerability and mutuality • Behaviors and activities: the initiation of safe and pleasurable sexual activities • Physical Function: the opportunity to experience the full range of human sexual response

47. Voices that Interfere with Sexual Fulfillment • Inner “voices” before, during and after sex interfere with sexual functioning and satisfaction (Firestone, Firestone & Catlett, 2006, pp. 229-262) • Why would he want to be in a relationship with you? • She is trying to control me. • Your penis is too small. • Your breasts are not like other women’s. • Don’t have oral sex, he’ll be repulsed. • You won’t be able to satisfy her. • He’ll think you are a slut. • You’re hurting her. • She’s too needy. • He’s unreliable. • You always give in; you have no dignity. • How do you know she had an orgasm?

48. Quieting the Voices • Each partner formulates the problem that he or she believes is limiting the sexual relationship. • Partners give voice to self-critical and negative partner perceptions. • They must contain (typically with the help of a therapist) the anger or sadness associated with verbalizing the inner voice. • Now the couple is free to explore the origins of negative cognitions, correcting early mistakes and distorted beliefs. • They plan together ways to change behaviors and communications in order to counteract the old dictates of their voices and to move toward mutually acceptable goals. • They may change contexts and circumstances associated with maintaining the voices • The couple can expect some strong “voice attacks” as they move toward sexual fulfillment • (Firestone, Firestone, & Catlett, 2006, pp. 235-237)

49. Archetypes and Individuation • According to Carl Jung’s model of growth, archetypes from the collective unconscious imbue the personal unconscious with psychic energy needed to progress toward higher levels of individuation or selfhood • Archetypes are integrated along the way • Awareness of the persona permits insight into roles • Coming to terms with the shadow reduces blaming, projection, and scapegoating of others • Integrating the contrasexual (anima/animus) makes meaning from sex differences and increases flexibility • Recognizing the “wise old man” and “the great mother” facilitates insight and wisdom • Making contact with the Self creates a new center for wholeness • (Clift, 1988)

50. Sexuality Counseling & Therapy