For Couples Therapists, Psychologists, and Physicians
Because Lirio’s primary care physician had recently retired, his annual checkup was with someone new, a doctor who had come highly recommended. During the exam, the doctor noticed some bruises on Lirio’s thighs and buttocks. Curious, he asked about them. “Oh, my boyfriend and I like to play rough,” Lirio smiled. The doctor “hm-mm’d” and continued the exam. When he did Lirio’s prostate exam (a lubricated, gloved finger in the rectum for two seconds), the doctor noticed some soreness, and Lirio grimaced slightly. “Take it easy there,” he said. “We played just last night.”
Lirio was an unusual patient: he actually talked about sex with his doctor. He didn’t feel embarrassed; in fact, he felt a little bad for the doc, who was clearly uncomfortable. Lirio was used to this, though, as he taught classes in S/M and was used to encountering various attitudes about it.
The doctor was concerned, though. “Just how roughly does your partner treat you?” he asked.
Lirio explained the completely consensual domination/submission relationship he had in bed with his boyfriend Juan. It included some spanking, whipping, and anal penetration. In all of these, both he and his partner pretended Lirio was powerless, forced to “submit.” I say “pretended” because Lirio and his partner had worked out the details of their game over time in a long series of conversations. Juan knew exactly what Lirio liked, what his limits were, and how to assess the impact of their play. Lirio was neither hesitant to ask for what he liked nor reluctant to say if he was too close to his limit.
So far, so good.
Except that the doc told Lirio that he looked like a victim of domestic abuse. “So I have to report this,” said the doctor.
Lirio thought he must be kidding, but he wasn’t. Trying to dissuade the doc, Lirio offered to call his boyfriend Juan to corroborate, but the doc wasn’t interested.
Lirio then described the theory and practice of S/M. With two other patients waiting, the doctor was getting impatient. “I can’t risk my family’s well-being by putting my license in jeopardy,” the doc said. It was surreal; Lirio was terrified. And he had only a minute or two to influence the well-meaning but naive doctor.
Suddenly Lirio had an idea. One of the office nurses seemed a little offbeat: black nail polish, a spiky leather wristband, tattoos, multiple earrings in each ear. Quickly finding her, he asked her to talk with the doctor on his behalf. It was humiliating—appealing to this stranger, who might be offended by his desperate assumption, to intervene with his own doctor, feeling like a criminal who had to marshal evidence to prevent a disaster.
The nurse turned out to be sympathetic (and into some vague S/M thing herself), and she immediately understood the importance of what Lirio was saying. She spoke with the doctor, who grudgingly dropped the whole thing. Attempting to be professional, he told Lirio, “Perhaps I’m not the right doctor for you.” “We agree on that,” said the relieved, stunned patient.
Lirio’s story isn’t unusual. In fact, data indicate that most patients involved in alternative sexual lifestyles don’t trust their physician with information that’s necessary for good health care. Lirio’s case shows why. But let’s back up a bit, and return to patients like Lirio later. First let’s talk about you and me.
Most clinicians get little or no training in sexuality (for example, California social workers are only required to take a single, ten-hour seminar). The training we do get is typically pathology-oriented: sex abuse, “sex addiction,” sexual violence, HIV rates, unintended pregnancy, sex tourism and trafficking. There’s rarely a mention of pleasure, the clitoris, or healthy non-monogamy.
And there’s rarely a mention of the enormous range of human sexual behaviors, unless it’s in the context of pathology (“a wide array of fetishes and paraphilias are known”). You can get licensed as a physician, marriage counselor, nurse, or social worker without ever hearing about, much less seeing, a vibrator.
This is bad for us both professionally and personally. It’s bad for our patients, too.
But it does mirror how most of our patients learn about sexuality: the theme is generally danger and fear, with rumors of orgiastic pleasure thrown in (without, of course, much instruction for bringing that about).
We’ve already seen that the Sexual Intelligence approach is the opposite of what most patients learn and experience. In many ways, it’s also the opposite of what professionals learn in our training. This appendix examines (and critiques) common responses to patients with sexual issues, and describes how a Sexual Intelligence approach can serve them better.
And if we grow ourselves while treating patients in a more sophisticated, humane way, that’s okay too. Everyone benefits when a professional gains a little Sexual Intelligence.
Noticing Our Assumptions so We Can Minimize Them
Most psychologists and physicians live in the same culture as their patients—they watch the same TV shows, use the same smart-phone apps, even go to the same church or gym.
A lot of our patients’ sexual (and relationship) difficulties are a direct result of their assumptions—about men, women, sex, love, intimacy, desire, and bodies. Patients typically hold certain problematic beliefs: that women should climax from intercourse; that erections should be ready-on-demand regardless of how a man feels; that desire is a natural outgrowth of love; that heterosexuals don’t (and shouldn’t) enjoy same-sex fantasies; and that sex should be natural and spontaneous. Beliefs like these undergird many common sexual difficulties.
Thus, a major part of successful treatment involves helping patients see their assumptions, discussing their unwanted consequences, and exploring alternative beliefs.
However, if we ourselves can’t see our patients’ assumptions, we obviously can’t point them out. And to the extent that we share those assumptions, it will be almost impossible to see them in a patient. Do you ever notice how everyone around you believes in gravity? No? Ever notice that people believe rain is wet? No? Ever notice that other people don’t eat soup with a knife? No? When we live as others do, it’s hard to notice what they do. Fish, as they say, don’t realize they live in water.
So if we as therapists and health care providers think that sex equals intercourse, we won’t notice when patients think so. If we think it’s unsexy or unromantic to use lubricants and condoms, or make dates for sex, we won’t notice when patients do. If we think that telling a partner what you like in bed is being bossy, we won’t notice when patients have the same attitude. What we don’t notice will make it impossible for us to diagnose, or to challenge such beliefs as the source of problems.
Thus, it’s crucial for us to know what our own sexual assumptions are. We don’t necessarily have to change them, but we need to know what they are, and we need to know that they’re not “right,” but merely a single point of view.
This presents a challenge not just to clinicians’ professional values but to their personal values and assumptions as well.
How Our Values Shape Our Work
As competent adult members of American culture, every therapist and physician has ideas about various aspects of sexuality. Is it okay for married people to masturbate? How much masturbation is “excessive”? Is homosexuality “normal”? How much sexual desire is “reasonable”? Is getting turned on by spanking “too kinky”? Like sexual variety itself, the questions are endless.
Note that there are no “right” or “scientific” answers to these questions. They refer to issues of values, not of fact. All of us have a sense of what’s “normal,” “right,” and “real” about sex, even if we don’t realize it. This sense about sexuality is such a deep part of our reality that it can be invisible to us—even when we’re conveying that sense as part of our clinical work.
Consider a few simple examples: We generally assume that married patients are monogamous. We often assume that a woman who’s had an abortion feels guilty or grief-stricken. We may ask patients their age when they first “had sex”—without specifying whether we mean partner sex, and if so, whether we mean intercourse (many people have oral sex or anal sex for years before first intercourse). And we may forget to ask if the sex was consensual, coercive, or something in between—a big lapse considering that a substantial number of first sexual experiences are not fully consensual.
Here are examples of values issues that shape our work—the questions we ask, our interpretations of the answers, and our suggestions based on those interpretations:
• What is “normal” sexuality?
• Sexually, what are “men” and “women” like?
• What is “normal” desire? What drives it?
• What is the relationship of fantasy, desire, and arousal?
• Can kinky sex be healthy? Can it involve intimacy?
• Can desires to surrender or dominate be healthy?
• What is the relationship between sex, love, and intimacy?
• What is the meaning of adult masturbation? What is its role in a relationship?
Note that it is primarily our non-professional ideas about these issues that shape our professional thinking and behavior: partly because we don’t get specialized training in sexuality, but also because we develop ideas about sexuality as ordinary adults in society. We wouldn’t make a similar professional leap in other areas in which we have no expertise—say, roofing or auto repair—even if we had opinions or general ideas as laypeople. Unfortunately, the clinical professions undervalue real expertise in sexuality; “reasonable” lay opinions in fancy language are more or less the state of the art.
And so we intervene in cases based on our ideas about, say, sexual submission (politically incorrect for women), exhibitionism (juvenile, hostile), casual sex (fear of intimacy), pornography (degrading to women, even when it shows women having pleasure), affairs (“sex addiction”), or same-gender fantasies (“latent homosexuality”). While each of these interpretations will be accurate for some patients, they will be wildly inaccurate for many others. If you walk into the consulting room with preconceived ideas like these, you’ll be ignoring the reality of a substantial number of your patients. Your world may feel validated, but theirs won’t. At least a quarter of my new patients are refugees from this sort of demeaning professional treatment.
Again, it doesn’t matter so much what your answers to values questions are; what matters is your awareness that you have those answers, that they’re probably based on your non-professional life, and that they shape your professional behavior without you realizing it. That’s what should grab your attention. And then every professional should spend some time identifying just what their sexual values are.
Sexual Function vs. Sexual Enjoyment
Some patients are very tangible in describing what they want from sex. They want better erections, or quicker lubrication, they want to last longer or climax quicker, they want more desire. Or they want their partner to change in these ways. They want someone’s “dysfunction” fixed, either their own or their partner’s.
If we choose, a good therapist or physician can investigate a patient’s life and often uncover the logic (conscious or unconscious) that makes sense of these “symptoms”: trauma, fear of abandonment, insecurity about masculinity, fear of intimacy—the whole Oprah-ocracy of inner torment we regularly see.
Given America’s twisted sexual culture, if we’re looking for stuff like that, we can almost always find it. Then, theoretically, we help our patients resolve it, the blocks to sexual function dissolve, and their genitalia are rescued from the ash heap of history. Good-bye, sexual “dysfunction.”
Whether that’s the best we can do for our patients is another matter.
I’m not so eager to agree that I’ll work with a patient to fix presenting problems like unreliable erections and discouraged vaginas. When I ask patients why these symptoms are a problem, their answers are often interesting, such as:
• “I’m afraid my partner will leave me.”
• “I don’t feel like a real man.”
• “It means God is angry that I masturbate.”
• “I’m afraid I’m gay.”
• “It means there’s something wrong with me.”
• “I’m afraid it means I don’t love my partner.”
• “I don’t want to get old.”
• “I’m afraid my partner will punish me.”
• “How will I ever find a partner, given my emotional baggage?”
I tell new patients that these aren’t sex problems. They’re insecurity, existential challenges, relationship problems, and misunderstandings about the nature of intimacy. Problems like these won’t be fixed by curing their sexual symptoms. Just as importantly, fixing their genitalia isn’t the key to the great sex that people say they want.
Professionals need to help people have better enjoyment rather than better functioning.
I approach sexual “function” as a means, not an end in itself. So memo to clinicians: quit working so hard to fix people’s erection, lubrication, and orgasm problems! Start dealing with their real difficulties: their perfectionism and resulting alienation from their bodies, their unrealistic expectations, their small-minded vision of sexuality, their performance anxiety.
It’s true, of course, that there are physiological problems that create sexual symptoms.
Some patients absolutely need a medical workup: those with shortness of breath (co-occurs with erection problems) and heavy menstrual bleeding (co-occurs with painful intercourse), to name just two. We want to make sure every patient has had a basic blood workup done within our lifetime; hypothyroidism and low testosterone or estrogen levels can create a wide range of mischief. When new middle-aged patients say that they haven’t seen a doctor in six years, I tell them they’ll need to do that as part of our treatment.
But diagnostically, let’s start simple. Remember: when you hear hooves, think horses, not zebras.
I’ve had dozens of new patients report that they received a prescription for an erection drug without being asked how they felt about their partner (many of them found their wives or girlfriends unappealing). I’ve known doctors to treat chronic yeast infections without finding out that, although the patient was having sex with her husband only every few months, she was regularly sleeping with someone else.
Finding out about our patients’ lives is a key part of treating their sexual issues. Or rather, it’s a key part of discovering which sexual issues need treating.
Identify Patients’ Sexual Narratives
As we’ve already seen, narratives are the stories that patients tell themselves (some consciously, others unconsciously) about who they are, what they can expect from sex, and what various experiences mean.
Some people have positive or neutral sexual narratives: I am attractive, capable, desirable. Or I’m good enough, I’m regular, I’m more or less normal. But people like this usually don’t come to our offices with sexual distress.
Instead, we see patients who think of themselves as damaged, inadequate, unattractive, godforsaken, old, blameworthy—in short, unsexy and ineligible for being desired or sexually satisfied.
This narrative itself can be critical to helping patients change their sexual experience. Addressing this narrative, rather than the balky vagina or penis or the elusive climax, is often the key.
Of course, it isn’t enough to say, “You think you’re damaged, but you’re not!” or, “You may feel unattractive, but I think you’re attractive!” You might as well tell a depressed person, “Have a nice day!” and expect it to lift their depression.
No, our job is more subtle. First we have to explain to patients what a narrative is; then we have to describe (to mirror) what their narrative is; then we have to help them investigate how their narrative undermines their sexual satisfaction; then we have to help them see that their narrative is a choice; and finally we have to help them weave a different narrative—one of adequacy and eligibility, one based on Sexual Intelligence rather than on killer abs or perfect breasts.
Deferring Too Much to Culture
America is far more conscious of its diversity now than ever before. So after decades of unconsciously imagining the “average” patient (white, middle-class, monogamous, sober), clinicians are now far more sensitive to the idiosyncratic cultural issues that accompany each new patient. “Diversity” is this decade’s big theme in both clinical and corporate training—what “don’t be a sexist pig” was three decades ago.
Nevertheless, while being sensitive to people’s individuality and idiosyncratic biographies, we don’t want to ignore our best tools or to make assumptions about our patients’ limitations. It’s true that, say, Asian people tend to be more private about their sexuality than Caucasians. And fundamentalist Christians tend to assume that women will submit to their husband’s sexual desires. And orthodox Jews generally believe masturbation is a sin. And, and, and….
But we also don’t want to stereotype people and cultures like we did in third grade. (You remember: “Holland: wooden shoes. India: elephants and tigers. Russia: drunk, impotent men.”) We want to walk a fine line: to be culturally sensitive without withholding our best work because we prejudge that people won’t be able to hear or value what we say.
This is especially true regarding religion. Inflexibility is inflexibility, regardless of the source. We can be respectful of patients’ beliefs and discuss the inevitable consequences of them at the same time. If, for example, a man believes it’s a sin to fantasize about women he sees on the street, that’s his right—but it’s going to make sex very complicated for him, and he deserves our best clinical insight about that. Similarly, if people insist that the only acceptable birth control is withdrawal before ejaculation, or that there are only a few days per month when a woman is clean enough to have intercourse, that’s their right—but that makes sex very complicated for them. We owe our patients clear information.
Here in Silicon Valley, I work with a lot of people who were born in Asia, or whose parents were born there. As a result, I periodically see patients involved with arranged marriages. Half of these people know their prospective spouse for months or even years; the other half meet their mate only weeks or even hours before the wedding.
Baldev and Gita both grew up in the coastal area of southern India. Their families had betrothed them in their early teens, and they married as college freshmen—having spent virtually no time together unchaperoned. Now in their mid-twenties, they’d been having sexual difficulties from the very start of their marriage. In addition, she wasn’t pregnant yet, and their families were pressuring them. “Don’t be a typical American,” his mother warned her, “postponing childbearing until you can only have one or two.”
As a Westerner, I find arranged marriage to be an alien institution, of course. But my patients and a half-dozen teaching trips across Asia have taught me a lot about its advantages and disadvantages. If Baldev and Gita had still been in India, they might have consulted with older siblings, clan elders, maybe a priest or doctor of traditional Ayurvedic medicine.
Here in California, they chose to see me. So how do we work with such people struggling with sexual difficulties?
After detailing their marital history, I looked at them and said, “You know, I’m not Indian.” They smiled at my small joke and relaxed a bit. “So I’m no expert on arranged marriages. But I do know a little bit, and you’ll tell me the rest of what I need to know.
“I appreciate that both your families were involved in your relationship even before it started,” I said. “So in a sense there are more than two of you in this marriage.” They nodded. “When we talk about sex, we usually think of the two people who are actually making love. But in your case that would be simplistic. Both your families were involved in the betrothal, the courtship, the wedding—two, three days, I bet, what an event!—and the honeymoon. Eagerly awaiting your first child, they’ve been in your bedroom ever since. This isn’t a criticism,” I emphasized, “just a description. Please tell me what this has been like for you.”
They were polite, a bit shy, and spoke in generalities and euphemisms. So I supplied a few words to help the conversation along. “I think almost any man would have trouble getting an erection if he felt people were looking over his shoulder,” I suggested. I gently continued, “And most women would find it hard to relax and let go if they imagined their mother or father in the next room.” I let my words sink in.
“Yes,” Baldev said quietly, “that’s kind of how it was. I think maybe you felt that way too, Gita?” Of course she did. So I went a step further.
“You’re both engineers, right? You know, it’s one thing to set people loose in a lab and tell them to work on a project. But imagine if they don’t know how to use the equipment, have no experience, don’t know each other well, are on a deadline—and they’re expected to work in the dark! How would that be?” They looked a little confused, so I spelled it out for them.
“You two were sent into a lab—your marital bed. Neither of you had any experience, you knew nothing about each other’s body, you didn’t know each other well enough to work as a team, and you felt you had to create a result—successful sex—on schedule. And to make it even harder to learn anything, you believed you had to do it in the dark!”
Their dark eyes opened wide as the accuracy of the description touched them. “And,” I concluded softly, “you’ve been operating under this kind of pressure, week after week, ever since. It must be a terrible strain.”
Gita was the first to speak. “I feel I’ve disappointed you many times,” she said to Baldev. “No, no,” her husband responded. “I’ve not been the man who … who…,” he choked back tears. “It’s all my fault.”
And that was the beginning of a series of very productive, if painful, sessions. Years of frustration, shame, and self-criticism—all suffered in emotional isolation from each other—suddenly had a voice. It was as if they were each discovering that they had a partner for the first time.
The expectations each had felt were such a burden.
“I thought I was supposed to excite you, but I didn’t know how—and I know my breasts are very small.”
“I heard there was something down there I was supposed to touch, but I couldn’t find it!”
“I hear other women love to … you know, orally satisfy the husband…. I didn’t know how to start, and I was afraid to hurt you.”
“I felt you were depending on me, and I wanted to succeed so much, and I felt so embarrassed.”
They were still young, and they did care for each other, and they were bright and open. And so a little information, a lot of communication, and the encouragement to begin their sexual relationship all over—starting with holding hands, kissing, and a couple of lingering pats on the behind—went a long way. After a few months, they waved good-bye to me, erotically more confident (in a sweetly shy way) and feeling more in charge of their lives than they’d ever imagined.
And although these details might be dramatically different than in the case of an American couple raised with sex, drugs, and rock ’n’ roll, the issues with most of my patients are similar: harsh expectations, inadequate information, emotional isolation, performance pressure, intercourse orientation, and the trivialization of individual sexual scripts.
By the way, when I teach in Asia I talk about changing the meaning of the Wedding Night: from “first intercourse” to “launching the couple’s sexual career, with touching and talking.” It’s a hard sell in traditional, procreation-oriented cultures, but I’m trying.
“Alternative” Sexuality
Whether we know it or not, a lot of our patients express their sexuality outside of traditional boundaries. They’re into S/M, three-somes, commercial sex, chat rooms, semi-public sex, swing clubs, and fetishes like gloves (rubber, leather, lace) or high heels (their own or others’; kissing them, wearing them, being stepped on by them). And of course our patients are involved with taboo activities that are hardly non-traditional—affairs and pornography, for example.
So how do we deal with these forms of sexual expressions? Without special training, we rely on what we already have—our own beliefs (prejudices?), our own experiences (positive or negative), and the vaguely suspicious, slightly negative, and altogether conventional sexual attitude of our profession.
Psychologists are committed to looking beyond the content of patients’ stories and lives, and focusing on situational and psychological dynamics. But this commitment often dwindles when the subject is sex. Whereas we don’t usually tell patients how to run their lives, we often tell them what not to do sexually; whereas we don’t usually tell them whether one or another approach to life is “normal” (even if they ask!), we eagerly opine on the normality of their sex lives—frequently pathologizing what they do or desire.
Physicians have learned to talk to patients about lifestyle tradeoffs; for example, orthopedists routinely tell patients that if tennis brings them pleasure, maybe accepting a little knee pain is a good choice. While doctors generally look to patients’ values and lifestyle when considering interventions, they are often too uncomfortable to do that regarding sex, substituting moralizing for medicine.
Many patients live with years of secrecy and shame, which almost always hurts them far more than whatever their sexual preferences are. I see men tearfully confess to masturbating into their wife’s panties, for example, and women anxiously confess to thinking about another woman in order to climax with a boyfriend. Decades of hiding and feeling guilty undermine both sexual function and intimacy. Often, such people lose their desire because, unconsciously, it’s the easiest way to distance themselves from their pain.
When patients ask us to fix their sexuality, we should go very, very slowly. Our initial goal should be sympathizing with their secrecy and shame, not changing their sexual expression. If the latter comes up at all—and it may not, if we effectively treat their emotional pain—it should be at the end of treatment, not the beginning.
We also need to understand that many aspects of “alternative” relationships are not necessarily about the sexual dynamic. When couples who happily swing can’t agree on whether their kid should have to earn his allowance or get it free, or on how to deal with the in-laws, or what to do about one of them being chronically late, their swinging is probably irrelevant. People into sexual expressions like bisexuality, S/M, or role-playing have the same rest-of-a-life that more traditional people have. So when faced with a patient involved in alternative sexual experiences, don’t be too quick to make that the centerpiece of the patient’s life or your treatment. However difficult it is, don’t let your own discomfort undermine the helpful neutrality that all patients need.
When This Approach Challenges the Clinician
Since most clinicians are marinating in the same distorted, sex-negative culture as our patients, we should assume that we’ve all internalized some version of the limited belief system about “normal sex” and “performance” that haunts our patients. And so, if we successfully challenge our patients’ allegiance to this way of thinking, we will inevitably confront our own allegiance to the same dysfunctional ideas.
This can be quite spectacular.
You might actually become aware of your own “ineligible/inadequate” narrative. You might realize that you feel resentful or self-critical about the ways in which you’ve accepted others’ limitations of your sexuality, or imposed limitations on yourself. You might discover that you’re still in some sexual closet or other regarding your mate.
You might become jealous of patients who liberate themselves. You might resent their spouses who try to prevent that. You might become nervous about the impulses inside you that you’ve safely tucked away as impractical, not normal, or not real. And you might feel grief—over what you’ve given up, sold too cheaply, or done without realizing it.
Grief is an important stage in eventually appreciating who we have become, and what’s now available for us to pursue. Everyone’s afraid to grieve, although we all want the serenity and energy on the other side of grief. You know, “Everyone wants to get to heaven, but nobody wants to die….”