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

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Publication Date: 
Thu, 2013-10-31


New Directions in Sex Therapy: Innovations and Alternatives edited by Peggy J. Kleinplatz, New York, Routledge 2012. 

Review by Meg Barker.

The request from Network magazine to review New Directions was a timely one for me. The book raises issues that are very much alive in my world of UK sex therapy at the moment, as well as in the American and Canadian context in which most of the contributing authors are writing.

In some ways the book's subtitle is more accurate than the main title because it presents a genuine alternative to standard thinking in sex therapy. Rather than providing one possible new direction, it gives us a much-needed critique of existing ways of understanding, and working with, sex in the therapy room.

The backdrop to this, for those who aren't familiar with sex therapy, is one of increasing categorization and measurement of sexual problems, and medicalization and individualization of treatments. Several of the contributors to the collection set out a history of sex therapy which began with Masters and Johnsons' attempts to determine a sexual response cycle across all humans; continued with the delineation of different “sexual dysfunctions” in the American Psychiatric Association's Diagnostic and Statistical Manual (DSM); and culminated in a post-Viagra rush to pharmaceutical and physiological solutions and randomized control trial tests of their effectiveness. 

The authors in this edited book share a skepticism toward this standard approach to sex therapy and a supreme discomfort with the underlying assumptions about sex. Instead of categorizing sexual “dysfunctions” (such as “erectile disorder” or “female orgasmic disorder”), contributors suggest that any sexual experience (including erections, orgasms, or their lack) will have very different meanings for each person, related to the relationships and wider culture in which they are embedded. Therefore instead of “treatment” of problems with specific medical or behavioural interventions, the therapeutic task becomes one understanding clients' experiences and what they mean for them.

Rather than measuring and explaining the causes of sexual problems, the goal of sexology becomes one of capturing the diversity of sexual experiences and understanding them within the specific social, historical, and cultural context. For example, David Ribner highlights the different meanings that sexual experiences have across cultural groups, whilst Marny Hall, Alex Carballo-Dieguez and colleagues, and Arlene Lev and Shannon Sennott, draw attention to the specific understandings of sex in lesbian, gay, bisexual and trans (LGBT) communities.

Whilst therapists may like to think of themselves as objective practitioners, drawing upon scientific facts about sexual functioning and dysfunctioning, Paul Joannides offers an important reminder that what we regard as ”problematic,” as ”sex,” or as ”distress,” for example, will be highly influenced by the client group we work with, by our theoretical approach, and by our familiarity with diverse sexual practices. The definition of ”problematic sexual behaviour” will likely vary a great deal across adult psychotherapy, forensic practice, and youth work. Our understanding of what constitutes sex will likely be much broader if we live and work in multicultural areas, or areas with significant LGBT and kink communities.

The Goldilocks amount of sex that is considered appropriate (not too little, not too much) will vary greatly between individual practitioners and theoretical approaches. Joannides gives the example of one study that regarded masturbation due to loneliness as a sign of sexual addiction. What level of loneliness is acceptable in life? And who determines the “correct” reasons for masturbation? Sexual addiction tests also include items such as: accessing pornography, hiding sexual behaviours from others, fantasizing to escape problems, and feeling badly about sexual behaviour, all of which are surely commonplace in contemporary culture with its paradoxical obsessions and aversions around sex.

Several authors in the book locate the current problems with sex therapy in dualism: our general tendency to separate the mind and the body. In fact, as Christopher Aanstoos points out, we are embodied beings who experience the world through our brains and bodies and who cannot be separated from these. Every experience—sexual or otherwise—is complexly biopsychosocial rather than being divisible into purely biological or purely psychological (with no room for the social).

Charles Moser and Maura Devereux point out that medical and therapeutic sex practitioners often work separately, with medics determining and treating the physiological aspects of problems (diabetes or heart problems underlying erection difficulties for example) and therapists working with the psychological aspects (such as anxiety at not being able to ”perform”). An integrated approach would be more in keeping with a biopsychosocial understanding of human (including sexual) being. Gary Brooks and William Elder point out that dualistic separations have meant that general psychotherapy often doesn't address the sexual parts of people's lives, whilst sex therapists have become increasingly distant from the wider world of psychotherapy. This can mean that sex therapists lack the depth and complexity that other therapists bring to their practice, and become limited to treating delineated problems in restricted ways. 

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.

7. Offer multiple options to clients. They may choose to just do what works to enable erections, penetration, or orgasms, and we should honour that choice if so, but if we offer other alternatives alongside this they may choose, for example, to deepen their relationship, to transform their thinking about sex, or to address their lives more widely.

8. Aim higher than returning clients to adequate sexual functioning and work with them toward “sex worth wanting” though being vulnerable and authentic, and through tuning into their bodies and their engagement with others.

I agree with the contributors to this book that it behoves all practitioners who are engaged with sex (therapists, educators, health professionals, etc.) to look deeply into their own assumptions about sex, and to look critically outwards to the cultural messages around them. It simply is not enough to offer approaches that reproduce and reinforce problematic assumptions about what constitutes sex and sexual problems. We need to aim higher with our clients, and we need to work toward shifting the social norms and roles that maintain their suffering. I hope that this collection will encourage practitioners to critically consider the assumptions and practices that they may be taking for granted, and to start out in a new alternative direction that is truly transformative.

Meg Barker, Ph.D., is a Senior Lecturer in Psychology at the Open University, UK, sex and relationship therapist, and author of the book Rewriting the Rules.