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.