Book Review: New Directions in Sex Therapy: Innovations and Alternatives

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Publication Date: 
Thu, 2013-10-31

Bernard Apfelbaum points out the need to attend to how sex is infused with the social (as well as being biological and psychological). People struggle to be present in the sexual moment because of a “hidden curriculum” of social rules that they feel they should follow around what constitutes “good” or “proper” sex. Like many of the contributors to the volume, Bernard is suggesting that sex therapy needs to start looking outwards rather than inwards to the problematic cultures that we inhabit when it comes to sex.

Several contributors agree with Leonore Tiefer that an ethical sex therapist should be a social activist as well as working with individuals, given that it is clear that much of what is pathological actually resides in wider culture. This includes the notion of sex as performance rather than pleasure, restrictive gender socialization resulting in men's and women's roles that are impossible to live up to, and a limited view of what counts as “proper” sex. This leaves so many people panicking that they are “not normal.” Daniel Watter, Jeanne Shaw and others add that ethical sex therapy should involve more than simply relieving symptoms, and wonder when sex therapy became so detached from the rest of psychotherapy that it lost the aim of genuinely improving people's lives.

Along with the sustained critique of current sex therapy woven through the various chapters, this book provides much that is valuable to the practitioner. Several chapters offer particular techniques, illustrated with example case studies. For example, readers can find out about the Feedback-Informed Treatment approach, the Good Enough Sex model, experiential approaches, and a number of phenomenological and narrative therapy practices such as Gina Ogden's technique of encouraging clients to tell their sexual stories from four different quadrants (emotional, physical, mental and spiritual). As mentioned there are also helpful chapters about working with specific groups such as survivors of sexual abuse and HIV serodiscordant couples (where one partner is HIV positive and the other is not).

I only have two criticisms of the book: one specific and one general. The specific point is that, as with so many texts that rightly decide to include LGBT people, this book does so by including chapters only on lesbian, gay and trans clients. Given that the major problem faced by bisexual people is that of invisibility and erasure it seems a shame to reproduce this (and the common assumptions that bisexual issues will be the same as those facing either heterosexual or gay clients), especially when there are a number of academics and practitioners now who have specific expertise around bisexuality.

The general point relates to a further cultural assumption around sex and relationships, which seems to permeate many of the chapters and remains unquestioned across much of the book. This is the assumption that relationships should be sexual. Several chapters address the common problem brought to sex therapists of long-term couple relationships that are sexless. Most of these assume: 1) that the goal should be to get sex happening, and 2) that that sex should be with each other. Marny Hall, in her chapter on lesbian couples, does address problematic master narratives about the necessity of being sexual. However there is a general lack of engagement with the challenges emerging from asexual communities about the sexual imperative, or with the alternatives emerging from openly non-monogamous communities about the couple as the place where all sexual needs should be met. 

I would like to end this review with the part of the book I found most useful: the set of alternatives that editor Peggy Kleinplatz herself puts forward as potential future goals for sex therapy:

1. Focus on the ability to be present rather than trying to enable a certain kind of sexual performance (erections, penetration, orgasm, etc.) through understanding clients' subjective meanings and experiences.

2. Appreciate the uniqueness of each client and the huge variety of possible sexual practices and experiences that may work for them, rather than promoting a one-size-fits-all goal for therapy. Here Kleinplatz provocatively (and usefully, I think) suggests that sex therapists could learn a lot from professional dominatrices who make it their business to learn exactly what gets their clients off.

3. Promote social change through sex education and activism rather than continuing to reinforce a problematic normative sexual script (e.g. measuring men's worth by their last erection, buying into cultural ideas about ageing bodies and the value of maintaining youth, or assuming that women must be penetrated in order to maintain their relationships).

4. Be guided by clients rather than by categories of functioning and dysfunctioning. For example, rather than trying to get penises to penetrate or vaginas to be penetrated, we could attend to the whole person and to the sensible reasons why this might not be a safe or desirable thing to do (for example because they want to be valued for more than their sexual performance, because past relationships have left them fearful of letting people in, or because sex has become all about pleasing others with no attention to what turns them on).

5. Get to the core of clients' pain and joy, hopes and despair, and aim at transformation rather than simply safely promoting mediocre sex.

6. Foster deep-seated change in the ways clients relate to themselves, others, and sex, rather than just aiming to contain problematic (e.g. non-consensual) sexual behaviours.