Family Psychotherapy
Journal of Family Psychotherapy, 20:95–111, 2009 Copyright © Taylor & Francis Group, LLC ISSN: 0897-5353 print/1540-4080 online DOI: 10.1080/08975350902967218
WJFP0897-53531540-4080Journal of Family Psychotherapy, Vol. 20, No. 2-3, April 2009: pp. 1–27Journal of Family Psychotherapy
What Every Sex Therapist Needs To Know
What Every Sex Therapist Needs To KnowJ. Ridley
JANE RIDLEY Private Practice, West Berkshire, United Kingdom
This article outlines both the personal attributes and the knowledge base required by aspiring sex therapists. It focuses on the intercon- nected and interdependent nature of sexuality. The complex concept of social norms, a brief introduction to diagnosis and prevalence of sexual difficulties, the anatomy and physiology of sex, and the sexual response cycle are covered. Areas that are controversial or are currently being debated are identified, including concerns over the medicalization of sexuality and male/female differences. No attempt is made to cover the material in detail except to note their significance. Issue regarding therapy are left to other articles.
KEYWORDS sex therapist, sexual response cycle, sexuality, sexual behavior
INTRODUCTION
If you are considering training as a sex therapist today it is essential that you are a resilient and flexible person, nevertheless able to be firm about your own and others’ boundaries. You will constantly learn new aspects of your- self, your motivation, your sexual orientation, moral and social code, and your prejudices and excitements. Paradoxically, this means you will simulta- neously be developing and changing.
You may often explore with clients an unfamiliar world that provokes in you ideas, feeling, and fantasies that have been strangers to you; guilt or shame may become more familiar, as will sexual and other powerful feel- ings. Being open to monitor your reactions must become part of you and your daily work. Allowing yourself to learn and to respond to the clients’ world with empathy and without judgment will be stretching and enriching.
Address correspondence to Jane Ridley, Orchard Lodge, Sfichen’s Green, West Berkshire RG 8954, UK. E-mail: janeridley@tandj77.demon.co.uk
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A central aspect of becoming a sex therapist is your own curiosity, open- ness, and preparedness to learn, without prejudice.
Your openness must also encompass the clients’ reactions, attitudes, feelings, or fantasies toward you. Your age, dress, ethnicity, voice tone, choice of language, social or religious attitudes, likes and dislike, and preju- dices will be observed, noted, and judged by your clients. Since you rapidly become part of the client’s system, how you are perceived by clients will influence the outcome of your work together.
In the process of becoming a sex therapist, there is much to learn and understand. Concepts such as what is normal sexual behavior or how to define and understand sexual difficulties or dysfunctions are central. A clear knowledge of the anatomy and physiology of male and female sexuality, the sexual response cycle, and the impact of life events and ageing upon sexuality must be understood within an historical context and that of the individual, couple, family, or social network, as well as their ethnic or reli- gious affiliations. Physical and mental health, the use of drugs or alcohol, domestic violence, previous sexual or emotional abuse, and traumatic expe- riences all have an impact upon the individual’s sexual life. Specialist knowledge and skills may need to be learned to work with these client groups. Evidence from research and evaluative studies is constant emerging that may affect how one understands or approaches aspects of human behavior and must be constantly monitored and responded to.
Disentangling the interaction between organic, physical, individual, interrelational, social, or environmental factors can make you feel part of a tangled boundaryless web. However, the development of skills depends upon an awareness of the complex interaction between the physical and organic aspects of sexuality and the individual’s internal and external psy- chological world as well as the social network surrounding the individual or couple. Thinking and working systemically greatly facilitates this process. It is essential to use supervision to explore not only what is happening to cli- ents, but also what issues are being raised for you. Regular supervision will become an essential routine (Giami, 2001; Mann, 1997; Ridley, 2006).
Historically, therapy has developed down separate theoretical routes (Ridley, 2006). More recently there has been a movement toward an integra- tive approach enabling therapists to select, from the rich range of theoretical options, the approach most suited to each particular client. Crowe and Ridley (2000) describe a hierarchy of alternative interventions (ALIs), which offers the therapist guidelines on why and when to choose which approach and when it may be useful to move up or down the hierarchy during ther- apy to an ALI. Weeks and Hof (1994, 1995) developed the intersystem approach for this purpose. Clarity about the therapist’s use of theory and the ability to move between theories is an essential skill. “A good postulate here is; fire your theory before you fire your client, or your client fires you” (Weeks et al., 2005, p. 9). (See also Chapter 3, The Intersystems Approach).
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Throughout this journal issue the intersystems approach is used when assessing the impact upon the individual’s sexual function, the interplay between his or her psychological makeup and the interpersonal and social environment she or he inhabits. This parallels Crowe and Ridley’s model for assessment.
As sex therapists learn more about clients, difficult moral or legal issues can arise. Conflict between loyalty to the client, or client confidentiality, may seem at odds with society’s requirements. Knowing the limits of ther- apy and working within the professional codes of practice and the legal framework are essential and challenging (AAMFT, 2001; BASRT, n.d.). Sex therapists do not work outside the legal and social framework of the country (even though, occasionally it may feel that way). Working together with other professionals and knowing the limits of sexual therapy, when to seek help from other coprofessionals, and when to refer on are basic require- ments. Working together with psychiatrists, doctors, social workers, proba- tion, prison, or other welfare agencies then becomes a support for both therapist and client.
These personal attributes and rich knowledge base are essential requirements for the sex therapist who wishes to learn the intervention skills described throughout this journal issue and developed during clinical practice under professional supervision.
SEXUALITY AND SEXUAL BEHAVIOR
Social Norms
Human survival depends upon the physiological fact that, for the next gen- eration to be conceived, men and women must have sexual intercourse, however brief (in vitro fertilization, IVF, is now available to a select few). Societies have developed different ways of coping with this powerful and necessary creative force. Within a multicultural society at the beginning of the 21st century, one is faced with a multitude of social, religious, or ethnic practices affecting the individual, couple, or family. Any attempt to under- stand what is seen as “normal” sexual behavior must take account of this rich context.
Gender and gender issue such as whether lesbian, gay, bisexual, or transsexual have similar experience of sexuality as heterosexual men and women; whether men and women’s approach to sex is different will affect the way sexuality is understood (Basson, 2002; Komisaruk, Beyer-Flores, & Whipple, 2006; Ridley, 1999).
In 1973 the American Psychiatric Association ceased to consider homo- sexuality as pathological. “It is hard to overestimate the impact of this deci- sion. First declaring homosexuals as ‘normal’, or at least as normal as heterosexuals, undermined laws, civil commitment procedures and the
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practice of therapy itself” (Nichols & Shernoff, 2007, p. 393). The legal acceptance of gay, lesbian long-term relationships through the Civil Partner- ships Act (2004), implemented December 5, 2005, questions previous approaches to sexuality and sexual behavior within Britain.
Kinsey and coworkers (1948, 1953) were among the first to study and publish material regarding the sexual behavior of Americans between 1938 and 1952 and opened up sexual behavior as an appropriate area for study. Newport (1997) examining the concept of norms wrote, “The concept of a norm is mysterious because it refers to a concept which exists ‘out there’ as part of culture, but is something which generally, unlike laws, for example, is never written down or codified formally” (p. 1). He continues
Survey research provides an excellent mechanism for social scientists to use to analyse a society’s norms. If 80% of the members of a society agree that certain behaviour is appropriate in a given situation, then it can be hypothesised that this represents a fairly widely shared norm. If only 20% agree, the behaviour is more appropriately characterised as deviant, rather than normative (p. 1).
Newport wrote of the tension that exists between the basic sex drive and culture’s attempts to control or channel “this amazingly powerful instinct.”
The tensions, described by Newport (1997) are seen clearly between generations. Regarding premarital sex, 71% of the over 65s said premarital sex was wrong, while for 75% of the 18 to 29 year olds it was not wrong. Six percent of the over 65s and 50% of the 18 to 29 year olds had lived together before marriage. Seidman and Rieder (1994) examined sexual behavior in more detail by reviewing American surveys and analyzed the 1988–1990 General Social Survey, which indicated that most American…
